Provider Demographics
NPI:1194079632
Name:KOUROSH KHAMOOSHIAN M.D., P.C.
Entity type:Organization
Organization Name:KOUROSH KHAMOOSHIAN M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KOUROSH
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAMOOSHIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:858-373-9616
Mailing Address - Street 1:5555 RESERVOIR DR STE 303
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5181
Mailing Address - Country:US
Mailing Address - Phone:858-373-9616
Mailing Address - Fax:858-373-9619
Practice Address - Street 1:5555 RESERVOIR DR STE 303
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5181
Practice Address - Country:US
Practice Address - Phone:858-373-9616
Practice Address - Fax:858-373-9619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-06
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA110901261QC1500X, 310400000X, 314000000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADJ1227Medicare PIN