Provider Demographics
NPI:1831485705
Name:MIRHOSSEINI, ALI REZA (MD)
Entity Type:Individual
Prefix:
First Name:ALI
Middle Name:REZA
Last Name:MIRHOSSEINI
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 1:415 E HARDING WAY STE D
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-6118
Mailing Address - Country:US
Mailing Address - Phone:209-944-5750
Mailing Address - Fax:209-464-2684
Practice Address - Street 1:1530 BESSIE AVE STE 101
Practice Address - Street 2:
Practice Address - City:TRACY
Practice Address - State:CA
Practice Address - Zip Code:95376-3080
Practice Address - Country:US
Practice Address - Phone:209-832-0343
Practice Address - Fax:209-464-2684
Is Sole Proprietor?:No
Enumeration Date:2011-06-20
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA163378207RC0000X
IL036135296207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine