Provider Demographics
NPI:1013668805
Name:JAVANBAKHT, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:JAVANBAKHT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:880 FRANKLIN ST APT 501
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94102-6304
Mailing Address - Country:US
Mailing Address - Phone:805-729-8521
Mailing Address - Fax:
Practice Address - Street 1:880 FRANKLIN ST APT 501
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-6304
Practice Address - Country:US
Practice Address - Phone:805-729-8521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-12
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program