Provider Demographics
NPI:1003878307
Name:KHOSRAVI, SASHA FARSHID (DO)
Entity Type:Individual
Prefix:
First Name:SASHA
Middle Name:FARSHID
Last Name:KHOSRAVI
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:PO BOX 4925
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50305-4925
Mailing Address - Country:US
Mailing Address - Phone:515-643-6290
Mailing Address - Fax:515-643-6291
Practice Address - Street 1:411 LAUREL ST
Practice Address - Street 2:SUITE 3310
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50314-3017
Practice Address - Country:US
Practice Address - Phone:515-643-6290
Practice Address - Fax:515-643-6291
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA36752084P0800X, 2084P0804X
MO20040076072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI11382002Medicare PIN