Provider Demographics
NPI:1922414101
Name:FARI G KAMALPOUR DO INC
Entity Type:Organization
Organization Name:FARI G KAMALPOUR DO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FARI
Authorized Official - Middle Name:G
Authorized Official - Last Name:KAMALPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:818-730-1183
Mailing Address - Street 1:1049 AVENIDA LADERA
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-4308
Mailing Address - Country:US
Mailing Address - Phone:818-730-1183
Mailing Address - Fax:
Practice Address - Street 1:1049 AVENIDA LADERA
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-4308
Practice Address - Country:US
Practice Address - Phone:818-730-1183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-08
Last Update Date:2014-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A11842207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty