Provider Demographics
NPI:1295058907
Name:BENJAMIN J. KAVOOSSI MD INC
Entity type:Organization
Organization Name:BENJAMIN J. KAVOOSSI MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:KAVOOSSI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-985-2112
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-0148
Mailing Address - Country:US
Mailing Address - Phone:909-985-2112
Mailing Address - Fax:909-985-3411
Practice Address - Street 1:2720 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-1810
Practice Address - Country:US
Practice Address - Phone:909-593-6222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA94166207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty