Provider Demographics
NPI:1326003690
Name:POURMOGHADAM, KAMAL K (MD)
Entity Type:Individual
Prefix:DR
First Name:KAMAL
Middle Name:K
Last Name:POURMOGHADAM
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 1:1222 S ORANGE AVE
Mailing Address - Street 2:MP 817
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1215
Mailing Address - Country:US
Mailing Address - Phone:407-649-6907
Mailing Address - Fax:407-481-2035
Practice Address - Street 1:1222 S ORANGE AVE
Practice Address - Street 2:MP 817
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1215
Practice Address - Country:US
Practice Address - Phone:407-649-6907
Practice Address - Fax:407-481-2035
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067818L208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001759842Medicaid
PA035417Medicare ID - Type Unspecified
PA001759842Medicaid