Provider Demographics
NPI:1144592205
Name:KHOSRAVIANI, KHASHAYAR (MD)
Entity Type:Individual
Prefix:
First Name:KHASHAYAR
Middle Name:
Last Name:KHOSRAVIANI
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 1:401 BICENTENNIAL WAY
Mailing Address - Street 2:DEPT OF RHEUMATOLOGY SUITE 160
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2149
Mailing Address - Country:US
Mailing Address - Phone:707-393-4155
Mailing Address - Fax:
Practice Address - Street 1:401 BICENTENNIAL WAY
Practice Address - Street 2:DEPT OF RHEUMATOLOGY SUITE 160
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2149
Practice Address - Country:US
Practice Address - Phone:707-393-4155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-06
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA139927207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology