Healthcare Provider Details

I. General information

NPI: 1285660456
Provider Name (Legal Business Name): MARJAN CHEGOUNCHI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 E HARDY ST STE 205
INGLEWOOD CA
90301-4054
US

IV. Provider business mailing address

PO BOX 390005
SAN DIEGO CA
92149-0005
US

V. Phone/Fax

Practice location:
  • Phone: 310-671-6364
  • Fax: 310-671-8184
Mailing address:
  • Phone: 619-746-6530
  • Fax: 619-746-6528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA80479
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA80479
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: