Healthcare Provider Details

I. General information

NPI: 1366214413
Provider Name (Legal Business Name): COPA DE ORO MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12052 IMPERIAL HWY STE 102
NORWALK CA
90650-3091
US

IV. Provider business mailing address

12052 IMPERIAL HWY STE 102
NORWALK CA
90650-3091
US

V. Phone/Fax

Practice location:
  • Phone: 310-404-7171
  • Fax:
Mailing address:
  • Phone: 562-261-9330
  • Fax: 562-543-3134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: BAHMAN CHAVOSHAN
Title or Position: OWNER
Credential: MD
Phone: 562-261-9330