Provider Demographics
NPI:1639136336
Name:REGENTS OF UNIV OF CA
Entity Type:Organization
Organization Name:REGENTS OF UNIV OF CA
Other - Org Name:NEPHROLOGY-UNIV PHYSICIANS
Other - Org Type:Other Name
Authorized Official - Title/Position:CHAIRMAN NEPHROLOGY DIVISION
Authorized Official - Prefix:DR
Authorized Official - First Name:NOSTRATOLA
Authorized Official - Middle Name:DABIR
Authorized Official - Last Name:VAZIRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-456-5142
Mailing Address - Street 1:PO BOX 513359
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-3359
Mailing Address - Country:US
Mailing Address - Phone:714-456-6238
Mailing Address - Fax:714-456-7816
Practice Address - Street 1:101 CITY DR S
Practice Address - Street 2:BLDG 53, RTE 81
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868
Practice Address - Country:US
Practice Address - Phone:714-456-5142
Practice Address - Fax:714-456-7816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0065170Medicaid
CAW13446Medicare ID - Type UnspecifiedMCARE GRP ID