Provider Demographics
NPI:1184728479
Name:ETEHAD, SIAMAK P (MD)
Entity type:Individual
Prefix:DR
First Name:SIAMAK
Middle Name:P
Last Name:ETEHAD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:17075 DEVONSHIRE
Mailing Address - Street 2:#100
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325
Mailing Address - Country:US
Mailing Address - Phone:818-831-7767
Mailing Address - Fax:818-831-3757
Practice Address - Street 1:17075 DEVONSHIRE
Practice Address - Street 2:#100
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325
Practice Address - Country:US
Practice Address - Phone:818-831-7767
Practice Address - Fax:818-831-3757
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2008-09-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA43714207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A437140Medicaid
E02537Medicare UPIN
CA00A437140Medicaid