Provider Demographics
NPI:1043472533
Name:KAMALVAND, EHSAN JASON
Entity type:Individual
Prefix:
First Name:EHSAN
Middle Name:JASON
Last Name:KAMALVAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 MAIN ST
Mailing Address - Street 2:STE F
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-1778
Mailing Address - Country:US
Mailing Address - Phone:650-366-2900
Mailing Address - Fax:650-366-2908
Practice Address - Street 1:1635 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92865-1929
Practice Address - Country:US
Practice Address - Phone:714-282-9911
Practice Address - Fax:714-282-9811
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2018-10-31
Deactivation Date:2018-01-25
Deactivation Code:
Reactivation Date:2018-10-31
Provider Licenses
StateLicense IDTaxonomies
CAHA6014237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist