Provider Demographics
NPI:1396846721
Name:KOSARI, KAMBIZ (MD)
Entity Type:Individual
Prefix:DR
First Name:KAMBIZ
Middle Name:
Last Name:KOSARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:2854 HWY 55
Mailing Address - Street 2:SUITE 130
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55121-1447
Mailing Address - Country:US
Mailing Address - Phone:651-842-3386
Mailing Address - Fax:651-224-5273
Practice Address - Street 1:6850 SEPULVEDA BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-4446
Practice Address - Country:US
Practice Address - Phone:855-846-4712
Practice Address - Fax:888-472-9713
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA94773204F00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A947730Medicaid
CAH83393Medicare UPIN
CAWA94773AMedicare PIN