Provider Demographics
NPI:1104902378
Name:POORMEHR, SHAHROKH (DO)
Entity type:Individual
Prefix:DR
First Name:SHAHROKH
Middle Name:
Last Name:POORMEHR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24953 PASEO DE VALENCIA, #22A
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618
Mailing Address - Country:US
Mailing Address - Phone:949-860-1788
Mailing Address - Fax:949-472-4126
Practice Address - Street 1:24953 PASEO DE VALENCIA, #22A
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653
Practice Address - Country:US
Practice Address - Phone:949-527-1828
Practice Address - Fax:949-472-4126
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6385207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0020A63850OtherBLUE SHIELD
CA20A6385OtherSTATE LICENSE
CAP00133250OtherRAILROAD MEDICARE
CA00AX63850Medicaid
W20A6385BMedicare PIN