Provider Demographics
NPI:1578523593
Name:DASTGHEIB, KOUROSH (MD)
Entity Type:Individual
Prefix:
First Name:KOUROSH
Middle Name:
Last Name:DASTGHEIB
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 1:12665 GARDEN GROVE BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1917
Mailing Address - Country:US
Mailing Address - Phone:714-636-6282
Mailing Address - Fax:714-422-0960
Practice Address - Street 1:12665 GARDEN GROVE BLVD STE 301
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1917
Practice Address - Country:US
Practice Address - Phone:909-581-6732
Practice Address - Fax:909-581-6737
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85637207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
04531539OtherECFMG
PA100967496Medicaid
04531539OtherECFMG
077962PFGMedicare ID - Type Unspecified