Provider Demographics
NPI:1215032305
Name:KHOSHNEVIS, MATT REZA (MD)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:REZA
Last Name:KHOSHNEVIS
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 1:6565 FANNIN
Mailing Address - Street 2:FONDREN 270
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030
Mailing Address - Country:US
Mailing Address - Phone:713-441-3020
Mailing Address - Fax:713-793-7064
Practice Address - Street 1:6565 FANNIN
Practice Address - Street 2:FONDREN 270
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030
Practice Address - Country:US
Practice Address - Phone:713-441-3020
Practice Address - Fax:713-793-7064
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL2373207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX165783505Medicaid
TX165783505Medicaid