MEDICARE: DR. KAMRAN GHODSIAN 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
1	174400000X	Specialist	A41039	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942204409
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KAMRAN GHODSIAN M.D.

Provider Business Mailing Address
First Line	:	24502 PACIFIC PARK DR
Second Line	:	SUITE 105
City	:	ALISO VIEJO
State	:	CA
Zip	:	92656-3033
Country	:	US
Telephone Number	:	949-362-1515
Fax Number	:	949-362-7548

Provider Business Practice Location Address
First Line	:	24502 PACIFIC PARK DR
Second Line	:	SUITE 105
City	:	ALISO VIEJO
State	:	CA
Zip	:	92656-3033
Country	:	US
Telephone Number	:	949-362-1515
Fax Number	:	949-362-7548

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	01/26/2012

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