Healthcare Provider Details

I. General information

NPI: 1588198790
Provider Name (Legal Business Name): KIAVASH NIKKHOU MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 04/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 ROLLING OAKS DR SUITE 260
THOUSAND OAKS CA
91361-1029
US

IV. Provider business mailing address

415 ROLLING OAKS DR SUITE 260
THOUSAND OAKS CA
91361-1029
US

V. Phone/Fax

Practice location:
  • Phone: 805-371-4707
  • Fax:
Mailing address:
  • Phone: 805-371-4707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA130422
License Number StateCA

VIII. Authorized Official

Name: DR. KIAVASH NIKKHOU
Title or Position: PHYSICIAN- UROLOGIST
Credential: M.D.
Phone: 818-577-0571