Provider Demographics
NPI:1164470639
Name:VAFADOUSTE, GHOLAMREZA (MD)
Entity Type:Individual
Prefix:DR
First Name:GHOLAMREZA
Middle Name:
Last Name:VAFADOUSTE
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 4398
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95352-4398
Mailing Address - Country:US
Mailing Address - Phone:209-575-4575
Mailing Address - Fax:209-575-4598
Practice Address - Street 1:2141 COLORADO AVE
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-2011
Practice Address - Country:US
Practice Address - Phone:209-575-4575
Practice Address - Fax:209-575-4598
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2010-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79905207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A799050Medicaid
CA00A799050Medicaid
CAH12284Medicare UPIN