Provider Demographics
NPI:1255572590
Name:SEAN KOSSARI, M.D. A. PROF . CORP
Entity type:Organization
Organization Name:SEAN KOSSARI, M.D. A. PROF . CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHAHRAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KOSSARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-365-1616
Mailing Address - Street 1:14901 RINALDI ST
Mailing Address - Street 2:SUITE 320
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91345-1204
Mailing Address - Country:US
Mailing Address - Phone:818-365-1616
Mailing Address - Fax:
Practice Address - Street 1:14901 RINALDI STREET
Practice Address - Street 2:SUITE 320
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1204
Practice Address - Country:US
Practice Address - Phone:818-365-1616
Practice Address - Fax:818-365-1811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-17
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA685790207V00000X
CAA68579207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A685790Medicaid
CAA68579Medicare PIN
CA00A685790Medicaid