Provider Demographics
NPI:1831110923
Name:FARBOODY, GHOLAM H (MD)
Entity Type:Individual
Prefix:
First Name:GHOLAM
Middle Name:H
Last Name:FARBOODY
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 1:1500 S CENTRAL AVE
Mailing Address - Street 2:SUITE 221
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2530
Mailing Address - Country:US
Mailing Address - Phone:818-242-0475
Mailing Address - Fax:818-662-0260
Practice Address - Street 1:1500 S CENTRAL AVE
Practice Address - Street 2:SUITE 221
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2530
Practice Address - Country:US
Practice Address - Phone:818-242-0475
Practice Address - Fax:818-662-0260
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42647174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C426470Medicaid
CAWC42647FMedicare ID - Type Unspecified
CA00C426470Medicaid