Provider Demographics
NPI:1043608763
Name:EBADPOUR, KAMAL
Entity Type:Individual
Prefix:MR
First Name:KAMAL
Middle Name:
Last Name:EBADPOUR
Suffix:
Gender:M
Credentials:
Other - Prefix:MRS
Other - First Name:SEPIDEH
Other - Middle Name:
Other - Last Name:SOHRABI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13224 IROQUOIS RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-6384
Mailing Address - Country:US
Mailing Address - Phone:213-999-0995
Mailing Address - Fax:
Practice Address - Street 1:13224 IROQUOIS ROAD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308
Practice Address - Country:US
Practice Address - Phone:213-999-0995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA366426126372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA46-2760607Medicaid