Provider Demographics
NPI:1003856204
Name:VESAL, OMID (MD)
Entity type:Individual
Prefix:
First Name:OMID
Middle Name:
Last Name:VESAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 ALTON PARKWAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92606-5032
Mailing Address - Country:US
Mailing Address - Phone:949-222-2722
Mailing Address - Fax:949-222-9969
Practice Address - Street 1:2500 ALTON PARKWAY
Practice Address - Street 2:SUITE 101
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92606-5032
Practice Address - Country:US
Practice Address - Phone:949-222-2722
Practice Address - Fax:949-222-9969
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73459207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A734590OtherMEDICAL PIN
CAZZZ02120ZOtherMEDICARE GROUP PIN
CA00A734590OtherBLUE SHIELD PIN
CA00A734590OtherBLUE SHIELD PIN
CA00A734590OtherMEDICAL PIN