Provider Demographics
NPI:1750895694
Name:ALIREZA HALATI, MD MEDICAL CORPORATION
Entity type:Organization
Organization Name:ALIREZA HALATI, MD MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALIREZA
Authorized Official - Middle Name:
Authorized Official - Last Name:HALATI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-413-3455
Mailing Address - Street 1:3220 S BREA CANYON RD STE F
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-3481
Mailing Address - Country:US
Mailing Address - Phone:909-598-7868
Mailing Address - Fax:
Practice Address - Street 1:3220 S BREA CANYON RD STE F
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-3481
Practice Address - Country:US
Practice Address - Phone:909-598-7868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-30
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92433208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty