Provider Demographics
NPI:1275547390
Name:KHORSANDI, AMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:AMIN
Middle Name:
Last Name:KHORSANDI
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 1:2222 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2304
Mailing Address - Country:US
Mailing Address - Phone:310-449-0093
Mailing Address - Fax:310-449-9204
Practice Address - Street 1:2222 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2304
Practice Address - Country:US
Practice Address - Phone:310-449-0093
Practice Address - Fax:310-449-9204
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56357207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A563570Medicaid
CAA56357Medicare ID - Type UnspecifiedMEDICARE PROVIDER #
CA00A563570Medicaid