Healthcare Provider Details

I. General information

NPI: 1326003690
Provider Name (Legal Business Name): KAMAL K. POURMOGHADAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 04/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1222 S ORANGE AVE MP 817
ORLANDO FL
32806-1215
US

IV. Provider business mailing address

1222 S ORANGE AVE MP 817
ORLANDO FL
32806-1215
US

V. Phone/Fax

Practice location:
  • Phone: 407-649-6907
  • Fax: 407-481-2035
Mailing address:
  • Phone: 407-649-6907
  • Fax: 407-481-2035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD067818L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD067818L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: