Provider Demographics
NPI:1811004625
Name:LALEZARZADEH, FARIBORZ (DO)
Entity Type:Individual
Prefix:
First Name:FARIBORZ
Middle Name:
Last Name:LALEZARZADEH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 E REDLANDS BLVD STE U506
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6109
Mailing Address - Country:US
Mailing Address - Phone:909-883-8834
Mailing Address - Fax:909-883-8834
Practice Address - Street 1:164 W HOSPITALITY LN STE 100
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3316
Practice Address - Country:US
Practice Address - Phone:909-883-8834
Practice Address - Fax:909-644-4021
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA8309208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A83090OtherMEDICARE ID TYPE UNSPECIFIED
CAGR0079700Medicaid
CA020A83090Medicaid
CA020A83090Medicare PIN
ZZZ13858ZMedicare ID - Type Unspecified
CAGR0079700Medicaid