Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207Q00000X | Family Doctor | A153022 | CA |
NPI | 1003279621 |
---|---|
Provider Name | Soroosh Amanat |
First Address | San Diego, CA 92127-5705 |
Second Address | Chula Vista, CA 91914-3501 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 31/03/2016 |
Last Update Date | 06/10/2020 |