Provider Demographics
NPI:1770684326
Name:HADI, EHSAN M (MD)
Entity Type:Individual
Prefix:
First Name:EHSAN
Middle Name:M
Last Name:HADI
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 1:3400 DATA DRIVE
Mailing Address - Street 2:PHYSICIAN SUPPPRT SERVICES
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:916-379-2948
Mailing Address - Fax:916-858-7065
Practice Address - Street 1:6555 COYLE AVENUE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608
Practice Address - Country:US
Practice Address - Phone:916-536-3670
Practice Address - Fax:916-536-2480
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARBH8093320207Q00000X
CAA102040207Q00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK149547001Medicaid
5M435Medicare ID - Type Unspecified
AK149547001Medicaid