Provider Demographics
NPI:1609992171
Name:GHEYSAR, KENNETH KAMBIZ (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:KAMBIZ
Last Name:GHEYSAR
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 1:23046 AVENIDA DE LA CARLOTA STE 600
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-1537
Mailing Address - Country:US
Mailing Address - Phone:949-306-2566
Mailing Address - Fax:
Practice Address - Street 1:23046 AVENIDA DE LA CARLOTA STE 600
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1537
Practice Address - Country:US
Practice Address - Phone:949-306-2566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG 71924207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine