Healthcare Provider Details

I. General information

NPI: 1346822673
Provider Name (Legal Business Name): KHASHAYAR NATTAGH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2021
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CORPORATE PLAZA DR STE 220
NEWPORT BEACH CA
92660-7953
US

IV. Provider business mailing address

2 CORPORATE PLAZA DR STE 220
NEWPORT BEACH CA
92660-7953
US

V. Phone/Fax

Practice location:
  • Phone: 949-242-9172
  • Fax:
Mailing address:
  • Phone: 949-242-9162
  • Fax: 949-272-0883

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number189124
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPTL6535
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberPTL6535
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: