Healthcare Provider Details

I. General information

NPI: 1295104354
Provider Name (Legal Business Name): MATT REZA KHOSHNEVIS MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2015
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3851 KATELLA AVE SUITE 315
LOS ALAMITOS CA
90720-3309
US

IV. Provider business mailing address

3851 KATELLA AVE SUITE 315
LOS ALAMITOS CA
90720-3309
US

V. Phone/Fax

Practice location:
  • Phone: 562-626-8016
  • Fax:
Mailing address:
  • Phone: 562-626-8016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: LAURA QUINONEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 562-626-8016