Provider Demographics
NPI:1124042882
Name:HOSSEINIAN, GHOLAM REZA (MD,)
Entity Type:Individual
Prefix:
First Name:GHOLAM
Middle Name:REZA
Last Name:HOSSEINIAN
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 1:1030 W GARDENA BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-4956
Mailing Address - Country:US
Mailing Address - Phone:310-323-9999
Mailing Address - Fax:310-323-0216
Practice Address - Street 1:1030 W GARDENA BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4956
Practice Address - Country:US
Practice Address - Phone:310-323-9999
Practice Address - Fax:310-323-0216
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72485207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH83856Medicare UPIN