=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225856941
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIGESTIVE HEALTH AND NUTRITION, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2024
-----------------------------------------------------
Last Update Date | 04/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5222 BALBOA AVE STE 42
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92117-6991
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-649-7100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6675 ELEGANTE WAY
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92130-5403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-342-8614
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | KOOROSH KOOROS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 760-649-1700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0206X
-----------------------------------------------------
Taxonomy Name | Pediatric Gastroenterology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------