Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207X00000X | Orthopaedic Surgeon | G79362 | CA |
N | 207XS0117X | Orthopaedic Spine Surgeon | G79362 | CA |
NPI | 1073621470 |
---|---|
Provider Name | Kourosh Kevin Shamlou |
First Address | Downey, CA 90241-5026 |
Second Address | Downey, CA 90241-5026 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/08/2006 |
Last Update Date | 02/08/2011 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G66088 | (02) |