Provider Demographics
NPI:1235123142
Name:MEHRANY, KHOSROW (MD)
Entity Type:Individual
Prefix:
First Name:KHOSROW
Middle Name:
Last Name:MEHRANY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:MEHRANY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:64 MARIPOSA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95030-4317
Mailing Address - Country:US
Mailing Address - Phone:209-338-7758
Mailing Address - Fax:209-554-0311
Practice Address - Street 1:1729 TULLY RD STE 9
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4081
Practice Address - Country:US
Practice Address - Phone:209-338-7758
Practice Address - Fax:209-554-0311
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2021-06-21
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-13
Provider Licenses
StateLicense IDTaxonomies
CAA87519174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH16218Medicare UPIN