Provider Demographics
NPI:1801979018
Name:GHOVANLOU, PARISSA (MD)
Entity type:Individual
Prefix:
First Name:PARISSA
Middle Name:
Last Name:GHOVANLOU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4766 ADMIRALTY WAY
Mailing Address - Street 2:P.O. BOX 13100
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6978
Mailing Address - Country:US
Mailing Address - Phone:702-285-9277
Mailing Address - Fax:
Practice Address - Street 1:420 W ROWLAND ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-2943
Practice Address - Country:US
Practice Address - Phone:626-331-6411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV11921207Q00000X
CAA94378207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100510840Medicaid
NV103078Medicare PIN
CABN254ZMedicare PIN