Provider Demographics
NPI:1043705718
Name:FOLSOM LAKE PRIMARY CARE PC
Entity type:Organization
Organization Name:FOLSOM LAKE PRIMARY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HADI
Authorized Official - Middle Name:
Authorized Official - Last Name:FIROZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-790-0450
Mailing Address - Street 1:271 AMERICAN RIVER CANYON DR
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-7143
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2575 E BIDWELL ST STE 210
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-6446
Practice Address - Country:US
Practice Address - Phone:916-984-7850
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC56218207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty