Provider Demographics
NPI:1952466112
Name:MALEKSHAMRAN, KEYVAN (MD)
Entity Type:Individual
Prefix:
First Name:KEYVAN
Middle Name:
Last Name:MALEKSHAMRAN
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 1:69175 RAMON RD STE A
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-3344
Mailing Address - Country:US
Mailing Address - Phone:760-321-6776
Mailing Address - Fax:760-321-4036
Practice Address - Street 1:1121 E WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-2214
Practice Address - Country:US
Practice Address - Phone:760-871-0606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA94845208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA94845AOtherINDIVIDUAL PTAN
CAW3731OtherGROUP PTAN