Provider Demographics
NPI:1861410029
Name:HEDAYATI-RAD, AMIR H (MD)
Entity type:Individual
Prefix:DR
First Name:AMIR
Middle Name:H
Last Name:HEDAYATI-RAD
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 1:706 W BROADWAY # 100
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-1032
Mailing Address - Country:US
Mailing Address - Phone:818-507-6404
Mailing Address - Fax:818-507-6406
Practice Address - Street 1:706 W BROADWAY # 100
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-1032
Practice Address - Country:US
Practice Address - Phone:818-507-6404
Practice Address - Fax:818-507-6406
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60239207RC0000X, 207RI0011X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A602390Medicaid
CAP00319921OtherRAILROAD MEDICARE
CA1659578110OtherGROUP NPI NUMBER
CA00A602390Medicaid
CA1659578110OtherGROUP NPI NUMBER
CAWA60239BMedicare ID - Type Unspecified
CAW17976AMedicare PIN
WA60239BMedicare PIN
CAWA60239BMedicare PIN