Healthcare Provider Details

I. General information

NPI: 1043472533
Provider Name (Legal Business Name): EHSAN JASON KAMALVAND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2008
Last Update Date: 10/31/2018
Certification Date:
Deactivation Date: 01/25/2018
Reactivation Date: 10/31/2018

III. Provider practice location address

1635 E LINCOLN AVE
ORANGE CA
92865-1929
US

IV. Provider business mailing address

260 MAIN ST STE F
REDWOOD CITY CA
94063-1778
US

V. Phone/Fax

Practice location:
  • Phone: 714-282-9911
  • Fax: 714-282-9811
Mailing address:
  • Phone: 650-366-2900
  • Fax: 650-366-2908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA6014
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: