Healthcare Provider Details

I. General information

NPI: 1194079632
Provider Name (Legal Business Name): KOUROSH KHAMOOSHIAN MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2012
Last Update Date: 07/01/2025
Certification Date: 07/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 GROSSMONT CENTER DR STE 444
LA MESA CA
91942-3020
US

IV. Provider business mailing address

5565 GROSSMONT CENTER DR STE 444
LA MESA CA
91942-3020
US

V. Phone/Fax

Practice location:
  • Phone: 858-373-9616
  • Fax: 858-373-9619
Mailing address:
  • Phone: 858-373-9616
  • Fax: 858-373-9619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License NumberA110901
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KOUROSH KHAMOOSHIAN
Title or Position: OWNER / CEO
Credential: MD
Phone: 858-373-9616