Provider Demographics
NPI:1922192111
Name:VOSSOUGH, SIAVOSH (MD)
Entity Type:Individual
Prefix:
First Name:SIAVOSH
Middle Name:
Last Name:VOSSOUGH
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 1:851 FREMONT AVE
Mailing Address - Street 2:SUITE 112
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-5698
Mailing Address - Country:US
Mailing Address - Phone:650-949-2771
Mailing Address - Fax:650-949-2388
Practice Address - Street 1:851 FREMONT AVE
Practice Address - Street 2:SUITE 112
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-5698
Practice Address - Country:US
Practice Address - Phone:650-949-2771
Practice Address - Fax:650-949-2388
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA61091207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH70098Medicare UPIN