Provider Demographics
NPI:1003024464
Name:KHONSARY, SEYED ALI (MD)
Entity Type:Individual
Prefix:
First Name:SEYED ALI
Middle Name:
Last Name:KHONSARY
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 241963
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-9763
Mailing Address - Country:US
Mailing Address - Phone:310-204-1732
Mailing Address - Fax:310-204-2607
Practice Address - Street 1:2701 FIRESTONE BLVD
Practice Address - Street 2:SUITE W
Practice Address - City:SOUTH GATE
Practice Address - State:CA
Practice Address - Zip Code:90280-2778
Practice Address - Country:US
Practice Address - Phone:323-249-6162
Practice Address - Fax:323-563-0820
Is Sole Proprietor?:No
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44590207U00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA44590OtherPRIVATE INS. ID.