Healthcare Provider Details

I. General information

NPI: 1578311015
Provider Name (Legal Business Name): CARDIOLOGY VASCULAR & ENDOCRINOLOGY CENTER PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2024
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 LYNN RD
THOUSAND OAKS CA
91360-1904
US

IV. Provider business mailing address

2220 LYNN RD
THOUSAND OAKS CA
91360-1904
US

V. Phone/Fax

Practice location:
  • Phone: 661-395-3055
  • Fax:
Mailing address:
  • Phone: 661-395-3055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. KHAZAI BAHRAM
Title or Position: OWNER/PRESIDENT
Credential: M.D.
Phone: 615-557-6692