Healthcare Provider Details

I. General information

NPI: 1952466112
Provider Name (Legal Business Name): KEYVAN MALEKSHAMRAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 E WASHINGTON AVE
ESCONDIDO CA
92025-2214
US

IV. Provider business mailing address

69175 RAMON RD STE A
CATHEDRAL CITY CA
92234-3344
US

V. Phone/Fax

Practice location:
  • Phone: 760-871-0606
  • Fax:
Mailing address:
  • Phone: 760-321-6776
  • Fax: 760-321-4036

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA94845
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: