Provider Demographics
NPI:1487697132
Name:KOSSARI, SHAHRAM (MD)
Entity type:Individual
Prefix:
First Name:SHAHRAM
Middle Name:
Last Name:KOSSARI
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 1:14901 RINALDI STREET
Mailing Address - Street 2:SUITE 320
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91345
Mailing Address - Country:US
Mailing Address - Phone:818-365-1616
Mailing Address - Fax:818-365-1811
Practice Address - Street 1:14901 RINALDI STREET
Practice Address - Street 2:SUITE 320
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345
Practice Address - Country:US
Practice Address - Phone:818-365-1616
Practice Address - Fax:818-365-1811
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2015-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68579174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A685790Medicaid
CA00A685790Medicaid
CAA68579Medicare ID - Type UnspecifiedPROVIDER NUMBER