Provider Demographics
NPI:1629171202
Name:MANSHADI, RAMIN (MD)
Entity Type:Individual
Prefix:
First Name:RAMIN
Middle Name:
Last Name:MANSHADI
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:PO BOX 4344
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-0344
Mailing Address - Country:US
Mailing Address - Phone:209-942-1005
Mailing Address - Fax:209-942-0455
Practice Address - Street 1:2633 PACIFIC AVENUE
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204
Practice Address - Country:US
Practice Address - Phone:209-944-5530
Practice Address - Fax:209-944-5990
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2013-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A547390207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A547390Medicaid
CA060059808OtherRAILROAD MEDICARE
CA060059808OtherRAILROAD MEDICARE
CA00A547390Medicaid