Provider Demographics
NPI:1205074507
Name:AMIRGHOLIZADEH, KESHVAR
Entity type:Individual
Prefix:
First Name:KESHVAR
Middle Name:
Last Name:AMIRGHOLIZADEH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KESHVAR
Other - Middle Name:AMIRGHOLIZADEH
Other - Last Name:ZEINALI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3 MONTANAS ESTE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-2607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4250 BARRANCA PKWY STE F
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-1731
Practice Address - Country:US
Practice Address - Phone:949-552-3111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44044183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPHE435930Medicaid
CA1083794580Medicare NSC