Provider Demographics
NPI:1730516303
Name:SIAMAK ETEHAD, MD, INC. A MEDICAL CORPORATION
Entity type:Organization
Organization Name:SIAMAK ETEHAD, MD, INC. A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SIAMAK
Authorized Official - Middle Name:POUR
Authorized Official - Last Name:ETEHAD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-673-8185
Mailing Address - Street 1:PO BOX 280636
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91328-0636
Mailing Address - Country:US
Mailing Address - Phone:800-673-8185
Mailing Address - Fax:
Practice Address - Street 1:17075 DEVONSHIRE ST STE 100
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-5405
Practice Address - Country:US
Practice Address - Phone:800-673-8185
Practice Address - Fax:310-626-9765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-27
Last Update Date:2013-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43714207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A437140Medicaid