Healthcare Provider Details

I. General information

NPI: 1538368014
Provider Name (Legal Business Name): KAVEH BAHMANPOUR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3023 BUNKER HILL ST STE 106
SAN DIEGO CA
92109-5701
US

IV. Provider business mailing address

3023 BUNKER HILL ST STE 106
SAN DIEGO CA
92109-5701
US

V. Phone/Fax

Practice location:
  • Phone: 858-270-0010
  • Fax: 858-270-0011
Mailing address:
  • Phone: 858-270-0010
  • Fax: 858-270-0011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA109450
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberA109450
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: