Provider Demographics
NPI:1043220031
Name:MARDANZAI, JOSEPH YUSAF (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:YUSAF
Last Name:MARDANZAI
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 3888
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-8888
Mailing Address - Country:US
Mailing Address - Phone:925-718-6622
Mailing Address - Fax:
Practice Address - Street 1:11030 BOLLINGER CANYON RD
Practice Address - Street 2:STE 240
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94582-4874
Practice Address - Country:US
Practice Address - Phone:925-736-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80856207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A808560Medicaid
CA00A808560Medicaid
HIAQ379VMedicare PIN