Provider Demographics
NPI:1073256772
Name:SALEH, HOMAYUN
Entity Type:Individual
Prefix:
First Name:HOMAYUN
Middle Name:
Last Name:SALEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2803
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5325 BRODER BLVD
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-3309
Practice Address - Country:US
Practice Address - Phone:925-551-6701
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-19
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA61009363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant