Provider Demographics
NPI:1922049501
Name:KOOCHEK, KAMRAN (MD)
Entity Type:Individual
Prefix:DR
First Name:KAMRAN
Middle Name:
Last Name:KOOCHEK
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 1:4910 VAN NUYS BLVD
Mailing Address - Street 2:STE 108
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1757
Mailing Address - Country:US
Mailing Address - Phone:818-986-4211
Mailing Address - Fax:
Practice Address - Street 1:4910 VAN NUYS BLVD
Practice Address - Street 2:STE 108
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1757
Practice Address - Country:US
Practice Address - Phone:818-986-4211
Practice Address - Fax:818-986-4215
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA778342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A778340OtherBLUE SHIELD
CA00A778340Medicaid
CA00A778340OtherBLUE SHIELD
CA00A778340Medicaid
CAAT610XMedicare PIN
CAH59667Medicare UPIN
CAAT610YMedicare PIN
CA00A778343Medicare PIN
CAAT610ZMedicare PIN