Healthcare Provider Details

I. General information

NPI: 1093941171
Provider Name (Legal Business Name): PEYMAN KABOLIZADEH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 10/15/2025
Certification Date: 10/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18111 BROOKHURST ST STE LL0300
FOUNTAIN VALLEY CA
92708-6728
US

IV. Provider business mailing address

PO BOX 844945
LOS ANGELES CA
90084-4945
US

V. Phone/Fax

Practice location:
  • Phone: 714-962-7100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

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 StateVA
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberA152224
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: