Provider Demographics
NPI:1265993299
Name:ROSTAMI JAFARABAD, SIAVASH
Entity type:Individual
Prefix:
First Name:SIAVASH
Middle Name:
Last Name:ROSTAMI JAFARABAD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 STEINWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-6329
Mailing Address - Country:US
Mailing Address - Phone:408-722-2778
Mailing Address - Fax:
Practice Address - Street 1:3076 MYRTLEDALE RD
Practice Address - Street 2:
Practice Address - City:CALISTOGA
Practice Address - State:CA
Practice Address - Zip Code:94515-1052
Practice Address - Country:US
Practice Address - Phone:707-403-8529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-31
Last Update Date:2022-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95172675163W00000X
CA95020089363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse