Provider Demographics
NPI:1245837566
Name:FARDAN, IRSHAD H (MBA)
Entity type:Individual
Prefix:
First Name:IRSHAD
Middle Name:H
Last Name:FARDAN
Suffix:
Gender:M
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2167 PASETTA DR APT 1
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:CA
Mailing Address - Zip Code:95050-3249
Mailing Address - Country:US
Mailing Address - Phone:408-204-8974
Mailing Address - Fax:
Practice Address - Street 1:2167 PASETTA DR APT 1
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-3249
Practice Address - Country:US
Practice Address - Phone:408-204-8974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes385H00000XRespite Care FacilityRespite Care
No171W00000XOther Service ProvidersContractorGroup - Single Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty