Healthcare Provider Details

I. General information

NPI: 1750607099
Provider Name (Legal Business Name): SEAN WILLIAM KALOOSTIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2010
Last Update Date: 09/05/2022
Certification Date: 02/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6276 RIVER CREST DR STE A
RIVERSIDE CA
92507-0783
US

IV. Provider business mailing address

6276 RIVER CREST DR STE A
RIVERSIDE CA
92507-0783
US

V. Phone/Fax

Practice location:
  • Phone: 951-413-0972
  • Fax:
Mailing address:
  • Phone: 951-413-0972
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberA118917
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: