Provider Demographics
NPI:1972535581
Name:ETEDALI, ELAHEH (DO)
Entity Type:Individual
Prefix:
First Name:ELAHEH
Middle Name:
Last Name:ETEDALI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1720
Mailing Address - Country:US
Mailing Address - Phone:760-729-4952
Mailing Address - Fax:760-729-2738
Practice Address - Street 1:2801 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1720
Practice Address - Country:US
Practice Address - Phone:760-729-4952
Practice Address - Fax:760-729-2738
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6701207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A67010OtherBLUE CROSS
CA00AX67010Medicaid
CA00AX67010Medicaid
CAI13507Medicare UPIN