Provider Demographics
NPI:1346411477
Name:KHAZAEIZADEH, ALIREZA (MD)
Entity Type:Individual
Prefix:DR
First Name:ALIREZA
Middle Name:
Last Name:KHAZAEIZADEH
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 1:2507 EASTBLUFF DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-3504
Mailing Address - Country:US
Mailing Address - Phone:949-200-1655
Mailing Address - Fax:949-200-1650
Practice Address - Street 1:2507 EASTBLUFF DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-3504
Practice Address - Country:US
Practice Address - Phone:949-200-1655
Practice Address - Fax:949-200-1650
Is Sole Proprietor?:No
Enumeration Date:2008-03-17
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA100885174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABA082Medicare PIN