Healthcare Provider Details

I. General information

NPI: 1952006843
Provider Name (Legal Business Name): IDEAN POURSHAMS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2023
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 LOWER RAGSDALE DR STE 100
MONTEREY CA
93940-5817
US

IV. Provider business mailing address

100 WILSON RD STE 100
MONTEREY CA
93940-7885
US

V. Phone/Fax

Practice location:
  • Phone: 831-649-1000
  • Fax:
Mailing address:
  • Phone: 831-649-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA207710
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: