Provider Demographics
NPI:1760803332
Name:TAYARANI BEEGHAM, MOHAMMAD
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:
Last Name:TAYARANI BEEGHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 WALNUT AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-2215
Mailing Address - Country:US
Mailing Address - Phone:510-745-9151
Mailing Address - Fax:
Practice Address - Street 1:3340 WALNUT AVE STE 140
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2215
Practice Address - Country:US
Practice Address - Phone:510-745-9151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103T00000X103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA390200000XMedicaid