Provider Demographics
NPI:1891876652
Name:BROUKHIM, KAMRAN H (MD)
Entity Type:Individual
Prefix:MR
First Name:KAMRAN
Middle Name:H
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:PO BOX 60790
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91116-6790
Mailing Address - Country:US
Mailing Address - Phone:626-204-6747
Mailing Address - Fax:626-396-0851
Practice Address - Street 1:12629 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:NORTH HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:91607-3488
Practice Address - Country:US
Practice Address - Phone:310-471-5852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG68940207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G689400Medicaid
CAG68940Medicare PIN