Provider Demographics
NPI:1861887077
Name:GHIASSI, KIA (DO)
Entity type:Individual
Prefix:
First Name:KIA
Middle Name:
Last Name:GHIASSI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24422 AVENIDA DE LA CARLOTA STE 275
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-3669
Mailing Address - Country:US
Mailing Address - Phone:949-354-3672
Mailing Address - Fax:
Practice Address - Street 1:24422 AVENIDA DE LA CARLOTA STE 275
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3669
Practice Address - Country:US
Practice Address - Phone:949-354-3672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-03
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A15558207RC0200X
MO2020012689207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine