Provider Demographics
NPI:1871005876
Name:VAHDATI, GELAREH
Entity Type:Individual
Prefix:
First Name:GELAREH
Middle Name:
Last Name:VAHDATI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 CARAWAY
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-3211
Mailing Address - Country:US
Mailing Address - Phone:310-906-9595
Mailing Address - Fax:
Practice Address - Street 1:4 CARAWAY
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-3211
Practice Address - Country:US
Practice Address - Phone:310-906-9595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-30
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA175751207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program