Provider Demographics
NPI:1073788667
Name:KHODABAKHSH, KASHYAR (MD)
Entity Type:Individual
Prefix:DR
First Name:KASHYAR
Middle Name:
Last Name:KHODABAKHSH
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 95000-2446
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-2446
Mailing Address - Country:US
Mailing Address - Phone:914-428-0529
Mailing Address - Fax:
Practice Address - Street 1:10 UNION SQ E
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3314
Practice Address - Country:US
Practice Address - Phone:914-428-0529
Practice Address - Fax:718-240-8607
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301090255208000000X
NY2583562084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics