Provider Demographics
NPI:1497993562
Name:A. ETEMADI MD, INC.
Entity Type:Organization
Organization Name:A. ETEMADI MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHAHNAZ
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-495-1416
Mailing Address - Street 1:24881 ALICIA PKWY STE N
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-4617
Mailing Address - Country:US
Mailing Address - Phone:949-510-2259
Mailing Address - Fax:949-388-3336
Practice Address - Street 1:24881 ALICIA PKWY STE N
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-4617
Practice Address - Country:US
Practice Address - Phone:949-510-2259
Practice Address - Fax:949-388-3336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-28
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G670930Medicaid
CAG67093OtherCA STATE LICENSE
CAZZZ56190YOtherBLUE SHIELD
CAZZZ56190YOtherBLUE SHIELD
CABL852AMedicare PIN