Provider Demographics
NPI:1518192038
Name:REZA VAFADOUSTE MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:REZA VAFADOUSTE MD A MEDICAL CORPORATION
Other - Org Name:MODESTO TURLOCK MERCED HEART & VASCULAR INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JUNE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-575-4575
Mailing Address - Street 1:PO BOX 4398
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95352-4398
Mailing Address - Country:US
Mailing Address - Phone:209-575-4575
Mailing Address - Fax:209-529-3260
Practice Address - Street 1:850 W OLIVE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-2427
Practice Address - Country:US
Practice Address - Phone:209-725-1990
Practice Address - Fax:209-529-3260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-28
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79905207RC0000X
CAA100098207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ27290ZMedicare PIN