=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306895974
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MANOUCHEHR SEYFZADEH M.D., PH.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2006
-----------------------------------------------------
Last Update Date | 07/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1820 FULLERTON AVENUE STE 360
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92881-3106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-270-4494
-----------------------------------------------------
Fax | 951-270-4495
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25422 TRABUCO RD STE 105-333
-----------------------------------------------------
City | LAKE FOREST
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92630-2791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-855-4439
-----------------------------------------------------
Fax | 888-978-2187
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | A062453
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------