Provider Demographics
NPI:1174557334
Name:HOOSHDARAN, FATANEH (DC)
Entity type:Individual
Prefix:DR
First Name:FATANEH
Middle Name:
Last Name:HOOSHDARAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 BLOSSOM HILL RD
Mailing Address - Street 2:SUITE#1
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-6349
Mailing Address - Country:US
Mailing Address - Phone:408-448-0247
Mailing Address - Fax:408-448-0176
Practice Address - Street 1:1610 BLOSSOM HILL RD
Practice Address - Street 2:SUITE#1
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-6349
Practice Address - Country:US
Practice Address - Phone:408-448-0247
Practice Address - Fax:408-448-0176
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC 29322111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC 0293221Medicare ID - Type Unspecified
CAU293221Medicare UPIN