Healthcare Provider Details

I. General information

NPI: 1942204409
Provider Name (Legal Business Name): KAMRAN GHODSIAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2005
Last Update Date: 01/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24502 PACIFIC PARK DR SUITE 105
ALISO VIEJO CA
92656-3033
US

IV. Provider business mailing address

24502 PACIFIC PARK DR SUITE 105
ALISO VIEJO CA
92656-3033
US

V. Phone/Fax

Practice location:
  • Phone: 949-362-1515
  • Fax: 949-362-7548
Mailing address:
  • Phone: 949-362-1515
  • Fax: 949-362-7548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA41039
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: