Provider Demographics
NPI:1033164330
Name:VAHDAT, OMID (MD)
Entity Type:Individual
Prefix:DR
First Name:OMID
Middle Name:
Last Name:VAHDAT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1817
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-1817
Mailing Address - Country:US
Mailing Address - Phone:562-598-0604
Mailing Address - Fax:562-598-1649
Practice Address - Street 1:3801 KATELLA AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-3338
Practice Address - Country:US
Practice Address - Phone:562-598-0604
Practice Address - Fax:562-598-1649
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64306207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A643060Medicaid
CA00A643060Medicaid
CAA64306Medicare ID - Type Unspecified