Healthcare Provider Details

I. General information

NPI: 1356372924
Provider Name (Legal Business Name): KOOROSH KOOROS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8110 BIRMINGHAM WAY
SAN DIEGO CA
92123-2758
US

IV. Provider business mailing address

3020 CHILDRENS WAY MC 5003
SAN DIEGO CA
92123-4223
US

V. Phone/Fax

Practice location:
  • Phone: 858-966-4032
  • Fax:
Mailing address:
  • Phone: 858-309-6300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberN7631
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number002125
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberC138035
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: