Provider Demographics
NPI:1770626905
Name:KOUKHAB, MANOOCHEHR (MD)
Entity type:Individual
Prefix:DR
First Name:MANOOCHEHR
Middle Name:
Last Name:KOUKHAB
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 1:3325 OAKRIDGE TER
Mailing Address - Street 2:
Mailing Address - City:CALABASAS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-3203
Mailing Address - Country:US
Mailing Address - Phone:818-224-3402
Mailing Address - Fax:
Practice Address - Street 1:3513 WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-1709
Practice Address - Country:US
Practice Address - Phone:323-262-1814
Practice Address - Fax:323-262-1699
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2014-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC427442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC42744OtherMEDICAL LICENSE