Healthcare Provider Details

I. General information

NPI: 1780902536
Provider Name (Legal Business Name): SOROUSH ZAGHI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2010
Last Update Date: 02/21/2025
Certification Date: 02/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10921 WILSHIRE BLVD SUITE 912
LOS ANGELES CA
90024-3906
US

IV. Provider business mailing address

10921 WILSHIRE BLVD STE 912
LOS ANGELES CA
90024-4003
US

V. Phone/Fax

Practice location:
  • Phone: 310-579-9710
  • Fax: 818-564-6921
Mailing address:
  • Phone: 310-579-9710
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberA119458
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207YS0012X
TaxonomySleep Medicine (Otolaryngology) Physician
License NumberA119458
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberA119458
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberA119458
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: