Provider Demographics
NPI:1053483800
Name:KAMRAVA, KAMRAN K (MD)
Entity Type:Individual
Prefix:
First Name:KAMRAN
Middle Name:K
Last Name:KAMRAVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6915 RESEDA BLVD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335
Mailing Address - Country:US
Mailing Address - Phone:818-343-2121
Mailing Address - Fax:818-705-1622
Practice Address - Street 1:6915 RESEDA BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335
Practice Address - Country:US
Practice Address - Phone:818-343-2121
Practice Address - Fax:818-705-1622
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43281208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A432810Medicaid
CA00A432810Medicaid
A43281Medicare ID - Type Unspecified