Provider Demographics
NPI:1508180456
Name:FALLAH, HESHAAM M (MD)
Entity Type:Individual
Prefix:
First Name:HESHAAM
Middle Name:M
Last Name:FALLAH
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 1:275 W MACARTHUR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94611-5641
Mailing Address - Country:US
Mailing Address - Phone:510-752-1000
Mailing Address - Fax:902-473-6855
Practice Address - Street 1:275 W MACARTHUR
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5641
Practice Address - Country:US
Practice Address - Phone:510-752-1000
Practice Address - Fax:902-473-6855
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA513351223S0112X
CAA106484204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery