Provider Demographics
NPI:1891722336
Name:EBRAHIMZADEH, HOTOSA (MD)
Entity Type:Individual
Prefix:DR
First Name:HOTOSA
Middle Name:
Last Name:EBRAHIMZADEH
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 1:150 AVENIDA CABRILLO
Mailing Address - Street 2:SUITE #A
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672
Mailing Address - Country:US
Mailing Address - Phone:949-369-6993
Mailing Address - Fax:949-369-6469
Practice Address - Street 1:150 AVENIDA CABRILLO
Practice Address - Street 2:SUITE #A
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672
Practice Address - Country:US
Practice Address - Phone:949-369-6993
Practice Address - Fax:949-369-6469
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65097207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A65070Medicaid
CAA65157OtherLICENSE
CAWA65097AMedicare ID - Type UnspecifiedMEDICARE #1C
CAA65157OtherLICENSE