Provider Demographics
NPI:1275734410
Name:FRED KHONSARI MEDICAL CORPORATION
Entity Type:Organization
Organization Name:FRED KHONSARI MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CORPORATION PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FERAIDOUN
Authorized Official - Middle Name:
Authorized Official - Last Name:KHONSARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-547-7457
Mailing Address - Street 1:1140 W LA VETA AVE
Mailing Address - Street 2:SUITE # 605
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4223
Mailing Address - Country:US
Mailing Address - Phone:714-547-7457
Mailing Address - Fax:714-547-6202
Practice Address - Street 1:1140 W LA VETA AVE
Practice Address - Street 2:SUITE # 605
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4223
Practice Address - Country:US
Practice Address - Phone:714-547-7457
Practice Address - Fax:714-547-6202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A310980Medicaid
CAA31098Medicare ID - Type Unspecified
CA00A310980Medicaid