Provider Demographics
NPI:1255549184
Name:BOGHAIRI, ANOUSHIRAVAN (MD)
Entity type:Individual
Prefix:
First Name:ANOUSHIRAVAN
Middle Name:
Last Name:BOGHAIRI
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 1:5565 GROSSMONT CENTER DRIVE
Mailing Address - Street 2:BLDG 1 STE 115
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942
Mailing Address - Country:US
Mailing Address - Phone:619-698-6667
Mailing Address - Fax:619-698-6684
Practice Address - Street 1:5565 GROSSMONT CENTER DRIVE
Practice Address - Street 2:BLDG 1 STE 115
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942
Practice Address - Country:US
Practice Address - Phone:619-698-6667
Practice Address - Fax:619-698-6684
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33832207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A338320Medicaid
B52037Medicare UPIN
CAA33832Medicare ID - Type Unspecified