Provider Demographics
NPI:1235200668
Name:BAMDAD, ALI REZA (DC)
Entity Type:Individual
Prefix:DR
First Name:ALI REZA
Middle Name:
Last Name:BAMDAD
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:ALEX
Other - Middle Name:
Other - Last Name:BAMDAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:1435 HUNTINGTON AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-5966
Mailing Address - Country:US
Mailing Address - Phone:650-794-1800
Mailing Address - Fax:650-794-1808
Practice Address - Street 1:1435 HUNTINGTON AVE STE 330
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-5966
Practice Address - Country:US
Practice Address - Phone:650-794-1800
Practice Address - Fax:650-794-1808
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC24280111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN0400XChiropractic ProvidersChiropractorNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU65147Medicare ID - Type Unspecified