Healthcare Provider Details

I. General information

NPI: 1326087727
Provider Name (Legal Business Name): AMIR ABBAS POURADIB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2006
Last Update Date: 05/13/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24012 CALLE DE LA PLATA STE 120
LAGUNA HILLS CA
92653-3632
US

IV. Provider business mailing address

PO BOX 4034
IRVINE CA
92616-4034
US

V. Phone/Fax

Practice location:
  • Phone: 949-588-7246
  • Fax: 949-272-3746
Mailing address:
  • Phone: 949-588-7246
  • Fax: 949-272-3746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA80929
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberA80929
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: