Provider Demographics
NPI:1619987617
Name:DANESHMAND, HOOTAN M (MD)
Entity Type:Individual
Prefix:
First Name:HOOTAN
Middle Name:M
Last Name:DANESHMAND
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 1:27462 PORTOLA PARKWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FOOTHILL RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:92610
Mailing Address - Country:US
Mailing Address - Phone:949-727-9099
Mailing Address - Fax:949-727-2030
Practice Address - Street 1:27462 PORTOLA PARKWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:FOOTHILL RANCH
Practice Address - State:CA
Practice Address - Zip Code:92610
Practice Address - Country:US
Practice Address - Phone:949-727-9099
Practice Address - Fax:949-727-2030
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73325208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
G73325Medicare UPIN
CAG29023Medicare ID - Type Unspecified