Healthcare Provider Details

I. General information

NPI: 1659523975
Provider Name (Legal Business Name): KOUROSH KHAMOOSHIAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2008
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: 888-475-6662
  • Fax: 858-408-3844
Mailing address:
  • Phone: 858-603-6576
  • Fax: 858-408-3844

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA110901
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA110901
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: