Provider Demographics
NPI:1609194570
Name:FERESHTEH JAHANPANAH A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:FERESHTEH JAHANPANAH A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FERESHTEH
Authorized Official - Middle Name:
Authorized Official - Last Name:JAHANPANAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-447-6001
Mailing Address - Street 1:1333 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92021-6540
Mailing Address - Country:US
Mailing Address - Phone:619-447-6001
Mailing Address - Fax:619-447-6096
Practice Address - Street 1:1333 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-6540
Practice Address - Country:US
Practice Address - Phone:619-447-6001
Practice Address - Fax:619-447-6096
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-17
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG65104207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1609194570Medicaid