Healthcare Provider Details

I. General information

NPI: 1245325984
Provider Name (Legal Business Name): CYRUS ANDRIS POURZAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 04/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 S. GOODWIN RD
LONE PINE CA
93545
US

IV. Provider business mailing address

52 N TU SU LN
BISHOP CA
93514-8058
US

V. Phone/Fax

Practice location:
  • Phone: 760-876-4795
  • Fax: 760-876-5624
Mailing address:
  • Phone: 760-873-6111
  • Fax: 760-872-8152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4876
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberG46209
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: