Provider Demographics
NPI:1184774374
Name:MOAZEMI, KOUROSH (MD)
Entity type:Individual
Prefix:
First Name:KOUROSH
Middle Name:
Last Name:MOAZEMI
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:PO BOX 276950
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-6950
Mailing Address - Country:US
Mailing Address - Phone:925-432-3318
Mailing Address - Fax:
Practice Address - Street 1:3901 LONE TREE WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-6200
Practice Address - Country:US
Practice Address - Phone:925-432-3318
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105401208M00000X
CAA78865208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA78865OtherCA LICENSE
H61021Medicare UPIN
ILH61021Medicare UPIN
ILIL3270149Medicare PIN
IL6447860003Medicare NSC