Healthcare Provider Details

I. General information

NPI: 1508935040
Provider Name (Legal Business Name): KOUROS AZAR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 10/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 HAALAND DR STE 200
THOUSAND OAKS CA
91361-5231
US

IV. Provider business mailing address

425 HAALAND DR STE 200
THOUSAND OAKS CA
91361-5231
US

V. Phone/Fax

Practice location:
  • Phone: 805-373-7073
  • Fax: 805-373-1116
Mailing address:
  • Phone: 805-373-7073
  • Fax: 805-373-1116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA79029
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: