Healthcare Provider Details

I. General information

NPI: 1497119960
Provider Name (Legal Business Name): SIAVASH BOLOURANI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2016
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

782 N MEDICAL CENTER DR E STE 101
CLOVIS CA
93611-6890
US

IV. Provider business mailing address

PO BOX 889442
LOS ANGELES CA
90088-9442
US

V. Phone/Fax

Practice location:
  • Phone: 559-256-4111
  • Fax: 559-256-4113
Mailing address:
  • Phone: 559-603-7372
  • Fax: 559-451-3661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA193634
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number000000000000
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code2086X0206X
TaxonomySurgical Oncology Physician
License NumberA193634
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: