Healthcare Provider Details

I. General information

NPI: 1861786873
Provider Name (Legal Business Name): BEHRANG HOSSEINI DEHKORDI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 MAUCHLY STE P
IRVINE CA
92618-6309
US

IV. Provider business mailing address

28241 CROWN VALLEY PKWY STE F312
LAGUNA NIGUEL CA
92677-4441
US

V. Phone/Fax

Practice location:
  • Phone: 949-354-4294
  • Fax:
Mailing address:
  • Phone: 646-525-2210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA138910
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: