Provider Demographics
NPI:1053401661
Name:KOUROSH, ATOOSA (MD)
Entity type:Individual
Prefix:DR
First Name:ATOOSA
Middle Name:
Last Name:KOUROSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 N CARROLL AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-5306
Mailing Address - Country:US
Mailing Address - Phone:214-702-6550
Mailing Address - Fax:214-894-4182
Practice Address - Street 1:1170 N CARROLL AVE
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-5306
Practice Address - Country:US
Practice Address - Phone:214-702-6550
Practice Address - Fax:214-894-4182
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00044424208000000X, 2080P0201X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/Immunology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01733874OtherRR MEDICARE WVH
WA1053401661Medicaid
WAG8958845, G8958846Medicare PIN