Basic Information
| Provider Information | |||||||||
| NPI: | 1770725897 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KOUROSH KHAMOOSHIAN MD, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14677 VIA BETTONA | ||||||||
| Address2: | SUITE 110, PMB 136 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921274809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583678601 | ||||||||
| FaxNumber: | 8584083844 | ||||||||
| Practice Location | |||||||||
| Address1: | 555 E VALLEY PKWY | ||||||||
| Address2: | |||||||||
| City: | ESCONDIDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920253048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7607393000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2009 | ||||||||
| LastUpdateDate: | 09/24/2012 | ||||||||
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| AuthorizedOfficialLastName: | KHAMOOSHIAN | ||||||||
| AuthorizedOfficialFirstName: | KOUROSH | ||||||||
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| AuthorizedOfficialTitleorPosition: | INTERNAL MEDICINE ATTENDING | ||||||||
| AuthorizedOfficialTelephone: | 8586036576 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | A110901 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | D4794 | 01 | CA | RESIDENCY NUMBER | OTHER |