Provider Demographics
NPI:1225199805
Name:SANEI FARD, BABAK (MD)
Entity Type:Individual
Prefix:DR
First Name:BABAK
Middle Name:
Last Name:SANEI FARD
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 1:414 G ST
Mailing Address - Street 2:SUITE 108
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-5663
Mailing Address - Country:US
Mailing Address - Phone:530-749-6628
Mailing Address - Fax:
Practice Address - Street 1:414 G ST
Practice Address - Street 2:SUITE 108
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5663
Practice Address - Country:US
Practice Address - Phone:530-749-6628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA112750207RI0011X, 207R00000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1225199805Medicaid
CA0A1127500OtherBLUE SHIELD PIN #
CA0A1127500OtherBLUE SHIELD PIN #
CA1225199805Medicaid