Provider Demographics
NPI:1578611380
Name:PEZESHKPOUR, GHOLAMHOSSEI (MD)
Entity Type:Individual
Prefix:
First Name:GHOLAMHOSSEI
Middle Name:
Last Name:PEZESHKPOUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GH
Other - Middle Name:
Other - Last Name:PEZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1001 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3502
Mailing Address - Country:US
Mailing Address - Phone:714-835-3555
Mailing Address - Fax:714-953-3541
Practice Address - Street 1:1001 N TUSTIN AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3502
Practice Address - Country:US
Practice Address - Phone:714-835-3555
Practice Address - Fax:714-953-3541
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC42944207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C429440Medicaid
F24052Medicare UPIN