Provider Demographics
NPI:1316041718
Name:ETEMADIAN, ALI M (DO)
Entity Type:Individual
Prefix:DR
First Name:ALI
Middle Name:M
Last Name:ETEMADIAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5343 RIVERSIDE DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710
Mailing Address - Country:US
Mailing Address - Phone:909-591-6227
Mailing Address - Fax:909-591-6319
Practice Address - Street 1:5343 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-4252
Practice Address - Country:US
Practice Address - Phone:909-591-6227
Practice Address - Fax:909-591-6319
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6377207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX63770Medicaid
CA00AX63770Medicaid
CAF72047Medicare UPIN