Provider Demographics
NPI:1073621470
Name:SHAMLOU, KOUROSH KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KOUROSH
Middle Name:KEVIN
Last Name:SHAMLOU
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 1:11411 BROOKSHIRE AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-5026
Mailing Address - Country:US
Mailing Address - Phone:562-869-4421
Mailing Address - Fax:562-869-3600
Practice Address - Street 1:11411 BROOKSHIRE AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-5026
Practice Address - Country:US
Practice Address - Phone:562-869-4421
Practice Address - Fax:562-869-3600
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-26
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79362207X00000X, 207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G79362Medicare ID - Type Unspecified
G66088Medicare UPIN
CABH626ZMedicare PIN