Healthcare Provider Details

I. General information

NPI: 1801082003
Provider Name (Legal Business Name): NOUREDDIN DEAN NOURBAKHSH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 05/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8001 FROST ST
SAN DIEGO CA
92123-2746
US

IV. Provider business mailing address

3020 CHILDRENS WAY MC5003
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-8052
  • Fax:
Mailing address:
  • Phone: 858-309-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number20A11746
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License Number20A11746
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: