Provider Demographics
NPI:1194134049
Name:MAHDAVI, ABBAS (MD)
Entity type:Individual
Prefix:
First Name:ABBAS
Middle Name:
Last Name:MAHDAVI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 LONE TREE WAY # 3
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-6018
Mailing Address - Country:US
Mailing Address - Phone:925-754-7200
Mailing Address - Fax:
Practice Address - Street 1:3700 LONE TREE WAY # 3
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-6018
Practice Address - Country:US
Practice Address - Phone:925-754-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31325208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A313250Medicaid