Provider Demographics
NPI:1275589723
Name:ROSHDIEH, BABAK (MD)
Entity Type:Individual
Prefix:
First Name:BABAK
Middle Name:
Last Name:ROSHDIEH
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 1:770 MAGNOLIA AVE
Mailing Address - Street 2:SUITE 2G
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3120
Mailing Address - Country:US
Mailing Address - Phone:951-734-6500
Mailing Address - Fax:951-734-6555
Practice Address - Street 1:770 MAGNOLIA AVE
Practice Address - Street 2:SUITE 2G
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3120
Practice Address - Country:US
Practice Address - Phone:951-734-6500
Practice Address - Fax:951-734-6555
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA76333207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH51277Medicare UPIN
CA00A763331Medicare ID - Type Unspecified