Provider Demographics
NPI:1760423123
Name:FARHADI, ASHKAN (MD)
Entity Type:Individual
Prefix:
First Name:ASHKAN
Middle Name:
Last Name:FARHADI
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 1:17360 BROOKHURST ST
Mailing Address - Street 2:ATTN: NETWORK MANAGEMENT
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708
Mailing Address - Country:US
Mailing Address - Phone:657-241-3592
Mailing Address - Fax:714-665-4614
Practice Address - Street 1:722 BAKER ST
Practice Address - Street 2:MEMORIAL CARE MEDICAL GROUP
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4320
Practice Address - Country:US
Practice Address - Phone:714-966-9523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC 53536207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABV725XMedicare PIN
ILI49274Medicare UPIN
ILK25045Medicare ID - Type Unspecified