Provider Demographics
NPI:1922205202
Name:KOUROSH ALEXANDER DASTGHEIB, M.D., INC
Entity type:Organization
Organization Name:KOUROSH ALEXANDER DASTGHEIB, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:ROWLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-356-4500
Mailing Address - Street 1:12665 GARDEN GROVE BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92843-1917
Mailing Address - Country:US
Mailing Address - Phone:949-652-6966
Mailing Address - Fax:714-422-0960
Practice Address - Street 1:12665 GARDEN GROVE BLVD
Practice Address - Street 2:STE 301
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92843-1917
Practice Address - Country:US
Practice Address - Phone:949-652-6966
Practice Address - Fax:714-422-0960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-29
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH02885Medicare UPIN