Provider Demographics
NPI:1013083179
Name:JAFARZADEH, MEHRDAD (MD)
Entity type:Individual
Prefix:
First Name:MEHRDAD
Middle Name:
Last Name:JAFARZADEH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MEHRDAD
Other - Middle Name:
Other - Last Name:JAFARZADEH-KHOSRARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3400 DATA DRIVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:916-564-3040
Mailing Address - Fax:916-564-3065
Practice Address - Street 1:6401 COYLE AVE STE 416
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608
Practice Address - Country:US
Practice Address - Phone:916-966-3501
Practice Address - Fax:916-966-2805
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66815207RC0000X, 207RI0011X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A668150Medicaid
CAGR0068233Medicaid
CAGR006823BMedicaid
CAGR0068230Medicaid
CAGR0068232Medicaid
CAZZZ47674ZOtherBLUE SHIELD
CAZZZ47676ZOtherBLUE SHIELD
CAGR0068235Medicaid
CAZZZ47673ZOtherBLUE SHIELD
CA060068134OtherRAILROAD MEDICARE
CAZZZ62306ZOtherBLUE SHIELD
CAGR0068231Medicaid
CAZZZ47676ZOtherBLUE SHIELD
CA00A668150Medicaid
CAZZZ00965ZMedicare PIN
CAZZZ47674ZOtherBLUE SHIELD
CAGR0068232Medicaid
CAGR0068233Medicaid
CAZZZ17828ZMedicare PIN
CAZZZ00968ZMedicare PIN