Provider Demographics
NPI:1063447134
Name:DANESH, SID ABRAHAM (MD)
Entity Type:Individual
Prefix:DR
First Name:SID
Middle Name:ABRAHAM
Last Name:DANESH
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 1:316 E LAS TUNAS DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-1535
Mailing Address - Country:US
Mailing Address - Phone:626-287-9949
Mailing Address - Fax:626-287-2982
Practice Address - Street 1:316 E LAS TUNAS DR
Practice Address - Street 2:SUITE 103
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1535
Practice Address - Country:US
Practice Address - Phone:626-287-9949
Practice Address - Fax:626-287-2982
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA39428207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A394280Medicaid
CAA39428Medicare ID - Type Unspecified
CA00A394280Medicaid