Provider Demographics
NPI:1952379174
Name:EGHBALI, KOUROSH (MD)
Entity Type:Individual
Prefix:DR
First Name:KOUROSH
Middle Name:
Last Name:EGHBALI
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 1:2601 W ALAMEDA AVE
Mailing Address - Street 2:#204
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-4800
Mailing Address - Country:US
Mailing Address - Phone:818-846-9999
Mailing Address - Fax:818-846-3160
Practice Address - Street 1:2601 W ALAMEDA AVE
Practice Address - Street 2:#204
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4800
Practice Address - Country:US
Practice Address - Phone:818-846-9999
Practice Address - Fax:818-846-3160
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78218207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A782180Medicaid
CAI12395Medicare UPIN
CA00A782180Medicaid