Basic Information
| Provider Information | |||||||||
| NPI: | 1154883940 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHOAPOUR | ||||||||
| FirstName: | CAMELLIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHOAEPOUR | ||||||||
| OtherFirstName: | KAMELIA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 26991 CROWN VALLEY PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495825430 | ||||||||
| FaxNumber: | 9493489513 | ||||||||
| Practice Location | |||||||||
| Address1: | 26991 CROWN VALLEY PKWY STE 100 | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495825430 | ||||||||
| FaxNumber: | 9493489513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2019 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | A180079 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.