Provider Demographics
NPI:1780731810
Name:KWIATKOUSKI, ANAHID JAVANFAR (DO)
Entity type:Individual
Prefix:
First Name:ANAHID
Middle Name:JAVANFAR
Last Name:KWIATKOUSKI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:ANAHID
Other - Middle Name:
Other - Last Name:JAVANFAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1970 S PROSPECT AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-6005
Mailing Address - Country:US
Mailing Address - Phone:310-944-9344
Mailing Address - Fax:
Practice Address - Street 1:1970 S PROSPECT AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-6005
Practice Address - Country:US
Practice Address - Phone:310-944-9344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A 9164207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine