Provider Demographics
NPI:1639177975
Name:ZIDEHSARAI, BEHROOZ (MD)
Entity Type:Individual
Prefix:
First Name:BEHROOZ
Middle Name:
Last Name:ZIDEHSARAI
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 496084
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96049-6084
Mailing Address - Country:US
Mailing Address - Phone:530-244-0720
Mailing Address - Fax:530-244-0972
Practice Address - Street 1:2005 COURT ST
Practice Address - Street 2:SUITE N
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1807
Practice Address - Country:US
Practice Address - Phone:530-244-0720
Practice Address - Fax:530-244-0972
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-11
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31117207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A311170Medicaid
CA00A311170Medicaid
A26354Medicare UPIN