Provider Demographics
NPI:1457540031
Name:BAGHERI, KOUROSH DARREN (MD, MS)
Entity Type:Individual
Prefix:DR
First Name:KOUROSH
Middle Name:DARREN
Last Name:BAGHERI
Suffix:
Gender:M
Credentials:MD, MS
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Mailing Address - Street 1:1177 MARSH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-2316
Mailing Address - Country:US
Mailing Address - Phone:805-781-9111
Mailing Address - Fax:805-788-0764
Practice Address - Street 1:170 SEACLIFF DR
Practice Address - Street 2:
Practice Address - City:SHELL BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-1715
Practice Address - Country:US
Practice Address - Phone:805-781-9111
Practice Address - Fax:818-208-8250
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG77496207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine