Healthcare Provider Details

I. General information

NPI: 1346652583
Provider Name (Legal Business Name): SEAN SIAMAK KHORAMI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2014
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9961 SIERRA AVE
FONTANA CA
92335-6720
US

IV. Provider business mailing address

17234 VALLEY BOULEVARD
FONTANA CA
92335
US

V. Phone/Fax

Practice location:
  • Phone: 909-427-2608
  • Fax: 909-427-5312
Mailing address:
  • Phone: 909-427-2608
  • Fax: 909-427-5312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA144435
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: