Healthcare Provider Details

I. General information

NPI: 1679159479
Provider Name (Legal Business Name): KEVIN KEON MAHMOUDI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 10/06/2026
Certification Date: 10/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

757 WESTWOOD PLZ
LOS ANGELES CA
90095-1101
US

IV. Provider business mailing address

1100 VAN NESS AVE FL 3
SAN FRANCISCO CA
94109-6978
US

V. Phone/Fax

Practice location:
  • Phone: 310-825-9111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA182550
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: