Provider Demographics
NPI:1477694156
Name:ALI M. ETEMADIAN, D.O., INC.
Entity Type:Organization
Organization Name:ALI M. ETEMADIAN, D.O., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALI
Authorized Official - Middle Name:M
Authorized Official - Last Name:ETEMADIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-591-6227
Mailing Address - Street 1:5343 RIVERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-4252
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6377207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX63770Medicaid
CA00AX63770Medicaid
CAF72047Medicare UPIN