Provider Demographics
NPI:1164593802
Name:JADALI, DARYOUSH (MD)
Entity Type:Individual
Prefix:DR
First Name:DARYOUSH
Middle Name:
Last Name:JADALI
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 7448
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91359-7448
Mailing Address - Country:US
Mailing Address - Phone:805-643-9781
Mailing Address - Fax:800-564-3878
Practice Address - Street 1:2100 LYNN RD
Practice Address - Street 2:SUITE 125
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-1935
Practice Address - Country:US
Practice Address - Phone:805-777-7406
Practice Address - Fax:805-554-4583
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48921207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A48921Medicaid
CA00A48921Medicaid