Provider Demographics
NPI:1619060456
Name:BROUKHIM, KAMRAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KAMRAN
Middle Name:
Last Name:BROUKHIM
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 1:19228 VENTURA BLVD
Mailing Address - Street 2:# D
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-3101
Mailing Address - Country:US
Mailing Address - Phone:818-693-3655
Mailing Address - Fax:818-999-1790
Practice Address - Street 1:19228 VENTURA BLVD
Practice Address - Street 2:# D
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-3101
Practice Address - Country:US
Practice Address - Phone:818-693-3655
Practice Address - Fax:818-999-1790
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38857207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A388570Medicaid
CA00A388570Medicaid
CAWA38857CMedicare PIN
CAWA38857DMedicare PIN