Provider Demographics
NPI:1225188089
Name:BAHRAMI, BAHRAM
Entity Type:Individual
Prefix:
First Name:BAHRAM
Middle Name:
Last Name:BAHRAMI
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:BAHRAM
Other - Middle Name:
Other - Last Name:BAHRAMI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:777 BANGOR ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92106-2951
Mailing Address - Country:US
Mailing Address - Phone:619-857-0063
Mailing Address - Fax:760-480-4350
Practice Address - Street 1:2934 INGELOW ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-2311
Practice Address - Country:US
Practice Address - Phone:760-480-4310
Practice Address - Fax:760-480-4350
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA-23638174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA-23638Medicare ID - Type Unspecified
CAA86685Medicare UPIN