Basic Information
| Provider Information | |||||||||
| NPI: | 1770626905 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOUKHAB | ||||||||
| FirstName: | MANOOCHEHR | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3325 OAKRIDGE TER | ||||||||
| Address2: | |||||||||
| City: | CALABASAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913023203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182243402 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3513 WHITTIER BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900231709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3232621814 | ||||||||
| FaxNumber: | 3232621699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 06/24/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | C42744 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | C42744 | 01 | CA | MEDICAL LICENSE | OTHER |