Provider Demographics
NPI:1255587630
Name:DERAKHSH FOZOUNI M.D. OB/GYN & ASSOCIATES A MEDICAL CORPORATION
Entity type:Organization
Organization Name:DERAKHSH FOZOUNI M.D. OB/GYN & ASSOCIATES A MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DERAKHSH
Authorized Official - Middle Name:
Authorized Official - Last Name:FOZOUNI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-668-0858
Mailing Address - Street 1:PO BOX 2462
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92263-2462
Mailing Address - Country:US
Mailing Address - Phone:760-327-2707
Mailing Address - Fax:
Practice Address - Street 1:555 E TACHEVAH DR
Practice Address - Street 2:SUITE 2W-103
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-5750
Practice Address - Country:US
Practice Address - Phone:760-327-2707
Practice Address - Fax:760-778-3780
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DERAKHSH FOZOUNI M.D. OB/GYN & ASSOCIATES A MEDICAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-18
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101294207V00000X
CAA95051207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty