Provider Demographics
NPI:1508062654
Name:GHASSEMI, KEVIN (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:
Last Name:GHASSEMI
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 1:100 UCLA MEDICAL PLAZA
Mailing Address - Street 2:SUITE 700
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-6970
Mailing Address - Country:US
Mailing Address - Phone:310-208-5400
Mailing Address - Fax:310-208-3788
Practice Address - Street 1:100 UCLA MEDICAL PLAZA
Practice Address - Street 2:SUITE 700
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-6970
Practice Address - Country:US
Practice Address - Phone:310-208-5400
Practice Address - Fax:310-208-3788
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2011-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92568207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1508062654OtherCCS PANELED
CA1508062654Medicaid
CADG753ZMedicare PIN