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NPI Code Detail

MEDICARE: DR. KENNETH KAMBIZ GHEYSAR M.D.

MEDICARE: DR. KENNETH KAMBIZ GHEYSAR M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207QA0401XAddiction Medicine (Family Medicine) PhysicianG 71924CA

General Provider Information

NPI Number : 1609992171
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KENNETH KAMBIZ GHEYSAR M.D.
Provider Business Mailing Address
First Line : 23046 AVENIDA DE LA CARLOTA STE 600
Second Line :
City : LAGUNA HILLS
State : CA
Zip : 92653-1537
Country : US
Telephone Number : 949-306-2566
Fax Number :
Provider Business Practice Location Address
First Line : 23046 AVENIDA DE LA CARLOTA STE 600
Second Line :
City : LAGUNA HILLS
State : CA
Zip : 92653-1537
Country : US
Telephone Number : 949-306-2566
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/22/2007
Last Update Date : 04/29/2022

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