Healthcare Provider Details

I. General information

NPI: 1245558105
Provider Name (Legal Business Name): AMIR POOYAN FAGHFOORY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2010
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27281 LAS RAMBLAS STE 200
MISSION VIEJO CA
92691-8303
US

IV. Provider business mailing address

27281 LAS RAMBLAS STE 200
MISSION VIEJO CA
92691-8303
US

V. Phone/Fax

Practice location:
  • Phone: 310-367-2532
  • Fax:
Mailing address:
  • Phone: 310-367-2532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA112232
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberD85191
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: