Provider Demographics
NPI:1407517246
Name:GHORBANI, ELHAM S (MD)
Entity Type:Individual
Prefix:
First Name:ELHAM
Middle Name:S
Last Name:GHORBANI
Suffix:
Gender:F
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:PO BOX 2153
Mailing Address - Street 2:
Mailing Address - City:TOLUCA LAKE
Mailing Address - State:CA
Mailing Address - Zip Code:91610-0153
Mailing Address - Country:US
Mailing Address - Phone:323-800-7999
Mailing Address - Fax:
Practice Address - Street 1:CALLE EXT. SUR 503
Practice Address - Street 2:
Practice Address - City:DORADO
Practice Address - State:PR
Practice Address - Zip Code:00646
Practice Address - Country:US
Practice Address - Phone:323-800-7999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-04
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR22625208D00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice