Provider Demographics
NPI:1689790750
Name:KIUMARS SAKETKHOO MD, INC
Entity Type:Organization
Organization Name:KIUMARS SAKETKHOO MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KIUMARS
Authorized Official - Middle Name:
Authorized Official - Last Name:SAKETKHOO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-789-5470
Mailing Address - Street 1:PO BOX 511225
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-3023
Mailing Address - Country:US
Mailing Address - Phone:562-789-5470
Mailing Address - Fax:562-789-4480
Practice Address - Street 1:12462 PUTNAM STREET
Practice Address - Street 2:STE 208
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90602-1005
Practice Address - Country:US
Practice Address - Phone:562-789-5470
Practice Address - Fax:562-789-4480
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2009-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA32779207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0084320Medicaid
CAGR0084320Medicaid
CAA26930Medicare UPIN