Provider Demographics
NPI:1932377033
Name:RANDJBAR, FREDERICK FARROKH (BOCPO)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:FARROKH
Last Name:RANDJBAR
Suffix:
Gender:M
Credentials:BOCPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3263
Mailing Address - Country:US
Mailing Address - Phone:714-563-0056
Mailing Address - Fax:
Practice Address - Street 1:321 E CENTER ST
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-3263
Practice Address - Country:US
Practice Address - Phone:714-563-0056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC21643225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXC0216430Medicaid
1922099159OtherTYPE 2 NPI #
CAXC0216430Medicaid