Provider Demographics
NPI:1962502195
Name:SACRAMENTO PEDIATRIC ENDOCRINE AND DIABETES MEDICAL CLINIC INC
Entity Type:Organization
Organization Name:SACRAMENTO PEDIATRIC ENDOCRINE AND DIABETES MEDICAL CLINIC INC
Other - Org Name:BAGHER M SHEIKHOLISLAM, MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BAGHER
Authorized Official - Middle Name:M
Authorized Official - Last Name:SHEIKHOLISLAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-733-6006
Mailing Address - Street 1:5301 F ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-3226
Mailing Address - Country:US
Mailing Address - Phone:916-733-6006
Mailing Address - Fax:916-454-1446
Practice Address - Street 1:5301 F ST
Practice Address - Street 2:SUITE 209
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3226
Practice Address - Country:US
Practice Address - Phone:916-733-6006
Practice Address - Fax:916-454-1446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23623174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA23623OtherLICENSE NUMBER