Provider Demographics
NPI:1053421123
Name:BAGHERI, BRUCE BEHROOZ (MD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:BEHROOZ
Last Name:BAGHERI
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 1:1560 E CHEVY CHASE DR
Mailing Address - Street 2:445
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4197
Mailing Address - Country:US
Mailing Address - Phone:818-247-3938
Mailing Address - Fax:818-247-7249
Practice Address - Street 1:1560 E CHEVY CHASE DR
Practice Address - Street 2:445
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4197
Practice Address - Country:US
Practice Address - Phone:818-247-3938
Practice Address - Fax:818-247-7249
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG70830207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G708300Medicaid
F57065Medicare UPIN
CAG70830Medicare ID - Type Unspecified