Provider Demographics
NPI:1124000757
Name:NOURISAMIE, KOUROSH (MD)
Entity Type:Individual
Prefix:
First Name:KOUROSH
Middle Name:
Last Name:NOURISAMIE
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 1:4241 LONG BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-2003
Mailing Address - Country:US
Mailing Address - Phone:562-912-2507
Mailing Address - Fax:484-916-2507
Practice Address - Street 1:4241 LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-2003
Practice Address - Country:US
Practice Address - Phone:562-912-2507
Practice Address - Fax:484-918-2507
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA817412085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
00A817410OtherBLUE SHIELD
CA00A817410Medicaid
H59130Medicare UPIN
CACB226826Medicare PIN
CA00A817410Medicaid
00A817410OtherBLUE SHIELD