Provider Demographics
NPI:1700802998
Name:FALLAHTAFTI, MAHDIEH (DO)
Entity Type:Individual
Prefix:DR
First Name:MAHDIEH
Middle Name:
Last Name:FALLAHTAFTI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4050 BARRANCA PKWY STE 260
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-1719
Mailing Address - Country:US
Mailing Address - Phone:949-654-0010
Mailing Address - Fax:949-654-8401
Practice Address - Street 1:4050 BARRANCA PKWY STE 260
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-1719
Practice Address - Country:US
Practice Address - Phone:949-654-0010
Practice Address - Fax:949-654-8401
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6766207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA203027854OtherTID
CAG64746Medicare UPIN