Provider Demographics
NPI:1245304856
Name:DANIALYPOUR, NOUROLLAH (MD)
Entity type:Individual
Prefix:MR
First Name:NOUROLLAH
Middle Name:
Last Name:DANIALYPOUR
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 1:5708 WATT AVENUE
Mailing Address - Street 2:
Mailing Address - City:NORTH HIGHLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:95660
Mailing Address - Country:US
Mailing Address - Phone:916-344-8866
Mailing Address - Fax:916-344-3979
Practice Address - Street 1:5708 WATT AVENUE
Practice Address - Street 2:
Practice Address - City:NORTH HIGHLANDS
Practice Address - State:CA
Practice Address - Zip Code:95660
Practice Address - Country:US
Practice Address - Phone:916-344-8866
Practice Address - Fax:916-344-3979
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A411140208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A411140OtherCA STATE LICENSE
CA8624117Medicaid
CA8624117Medicaid
CA1124218979OtherGROUP NPI NUMBER