Provider Demographics
NPI:1578785275
Name:BAGHERI, PEDRAM (MD)
Entity Type:Individual
Prefix:
First Name:PEDRAM
Middle Name:
Last Name:BAGHERI
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 1:662 CLEARWATER CREEK DR
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-4976
Mailing Address - Country:US
Mailing Address - Phone:805-822-4517
Mailing Address - Fax:
Practice Address - Street 1:1534 N MOORPARK RD
Practice Address - Street 2:291
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-5129
Practice Address - Country:US
Practice Address - Phone:805-497-1800
Practice Address - Fax:805-262-2558
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97085207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1578785275Medicaid
CACA119YMedicare PIN
CA1578785275Medicaid