Provider Demographics
NPI:1942204979
Name:HASSANI, FARZANEH (MD)
Entity Type:Individual
Prefix:
First Name:FARZANEH
Middle Name:
Last Name:HASSANI
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 1:1000 VALE TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92084-5218
Mailing Address - Country:US
Mailing Address - Phone:760-631-5000
Mailing Address - Fax:760-414-3892
Practice Address - Street 1:134 GRAPEVINE RD
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-4004
Practice Address - Country:US
Practice Address - Phone:760-631-5000
Practice Address - Fax:760-414-3892
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-08
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC54458207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV6000514000Medicaid
HA0898073OtherMEDICARE
110247165OtherRAILROAD MEDICARE
WV006895400OtherFED BLACKLLING
WV470880846001OtherWV BLUESHIELD
WV6000514000Medicaid
110247165OtherRAILROAD MEDICARE