Provider Demographics
NPI:1235210766
Name:KHOSHROU, DARYOUSH
Entity Type:Individual
Prefix:
First Name:DARYOUSH
Middle Name:
Last Name:KHOSHROU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 N TUSTIN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3612
Mailing Address - Country:US
Mailing Address - Phone:714-558-1310
Mailing Address - Fax:714-558-1320
Practice Address - Street 1:801 N TUSTIN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3612
Practice Address - Country:US
Practice Address - Phone:714-558-1310
Practice Address - Fax:714-558-1320
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49539174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A495390Medicaid