Provider Demographics
NPI:1326433525
Name:KHAZAELI, AZIN (MD)
Entity Type:Individual
Prefix:
First Name:AZIN
Middle Name:
Last Name:KHAZAELI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10531 4SCOMMONS DR 166 541
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127
Mailing Address - Country:US
Mailing Address - Phone:203-507-3870
Mailing Address - Fax:
Practice Address - Street 1:4445 EASTGATE MALL FL 2
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1979
Practice Address - Country:US
Practice Address - Phone:619-436-4691
Practice Address - Fax:415-484-1944
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-03
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA1542742084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program