Provider Demographics
NPI:1720387558
Name:JAVAHERI, KIANOUSH (MD)
Entity Type:Individual
Prefix:DR
First Name:KIANOUSH
Middle Name:
Last Name:JAVAHERI
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 1:300 FIR ST
Mailing Address - Street 2:SHARP REES-STEALY MEDICAL GROUP
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-2327
Mailing Address - Country:US
Mailing Address - Phone:858-499-2777
Mailing Address - Fax:
Practice Address - Street 1:300 FIR ST
Practice Address - Street 2:SHARP REES-STEALY MEDICAL GROUP
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2327
Practice Address - Country:US
Practice Address - Phone:858-499-2777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-18
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA 116084207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine