Healthcare Provider Details

I. General information

NPI: 1407315864
Provider Name (Legal Business Name): KAMRON A. FARIBA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2019
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W ROUTE 66 STE 202
GLENDORA CA
91740-4335
US

IV. Provider business mailing address

415 W ROUTE 66 STE 202
GLENDORA CA
91740-4335
US

V. Phone/Fax

Practice location:
  • Phone: 269-634-4676
  • Fax:
Mailing address:
  • Phone: 626-963-4467
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number34.016741
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A22760
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberU5391
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036171913
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number18239
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0548697
License Number StateKS
# 7
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberDO91264
License Number StateSC
# 8
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2023045462
License Number StateMO
# 9
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number202304562
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: