Provider Demographics
NPI:1790865038
Name:IZADI, HOMEIRA (MD)
Entity Type:Individual
Prefix:
First Name:HOMEIRA
Middle Name:
Last Name:IZADI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4061 E CASTRO VALLEY BLVD # 13
Mailing Address - Street 2:
Mailing Address - City:CASTRO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94552-4840
Mailing Address - Country:US
Mailing Address - Phone:650-487-0844
Mailing Address - Fax:650-924-9888
Practice Address - Street 1:325 SHARON PARK DRIVE
Practice Address - Street 2:D4
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025
Practice Address - Country:US
Practice Address - Phone:650-487-0844
Practice Address - Fax:650-924-9888
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86985208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173191101Medicaid
8D5166Medicare ID - Type Unspecified
TX173191101Medicaid