Provider Demographics
NPI:1245284686
Name:FATEMI, SHAHRAM (MD)
Entity type:Individual
Prefix:
First Name:SHAHRAM
Middle Name:
Last Name:FATEMI
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 1:3400 DATA DR
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:
Mailing Address - Fax:
Practice Address - Street 1:1700 N ROSE AVE
Practice Address - Street 2:SUITE 210
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-3790
Practice Address - Country:US
Practice Address - Phone:805-988-8058
Practice Address - Fax:805-983-0803
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80377207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM08609FMedicaid
CAZZT40394FMedicaid
CARHM08608FMedicaid
CA050394OtherBLUE CROSS
CA951683892OtherOTHER INSURANCE
CARHM18553HMedicaid
CAWA80377DMedicare ID - Type UnspecifiedPPIN
CAWA80377AMedicare ID - Type UnspecifiedPPIN
CARHM18553HMedicaid
CA050394OtherBLUE CROSS
CAZZT40394FMedicaid
H71113Medicare UPIN
CA050394Medicare ID - Type UnspecifiedMEDICARE
CA058553Medicare ID - Type UnspecifiedRH MEDICARE
CARHM08609FMedicaid
CARHM08608FMedicaid