Provider Demographics
NPI:1083663389
Name:MASOUD KETABCHI MD PA
Entity Type:Organization
Organization Name:MASOUD KETABCHI MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MASOUD
Authorized Official - Middle Name:
Authorized Official - Last Name:KETABCHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-654-5037
Mailing Address - Street 1:PO BOX 025483
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33102
Mailing Address - Country:US
Mailing Address - Phone:305-654-5037
Mailing Address - Fax:305-654-5237
Practice Address - Street 1:160 NW 170 ST
Practice Address - Street 2:PARKWAY REGIONAL MEDICAL CENTER
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162
Practice Address - Country:US
Practice Address - Phone:305-654-5037
Practice Address - Fax:305-654-5237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-06
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL253463100Medicaid
FL21598OtherBLUE CROSS BLUE SHIELD
FL253463100Medicaid