Provider Demographics
NPI:1891821187
Name:POURTEYMOUR, ARSALAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ARSALAN
Middle Name:
Last Name:POURTEYMOUR
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 1:724 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-5265
Mailing Address - Country:US
Mailing Address - Phone:909-875-8651
Mailing Address - Fax:909-875-8709
Practice Address - Street 1:724 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-5265
Practice Address - Country:US
Practice Address - Phone:909-875-8651
Practice Address - Fax:909-875-8709
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52564261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A525640Medicaid
CA00A525640Medicare ID - Type Unspecified
CAF72955Medicare UPIN