Provider Demographics
NPI:1346569779
Name:KHOSRAVIANI, ARDESHIR (MD)
Entity Type:Individual
Prefix:
First Name:ARDESHIR
Middle Name:
Last Name:KHOSRAVIANI
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:PO BOX 54130
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90054-0130
Mailing Address - Country:US
Mailing Address - Phone:951-687-3200
Mailing Address - Fax:951-687-8923
Practice Address - Street 1:3989 W STETSON AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-9695
Practice Address - Country:US
Practice Address - Phone:951-652-3558
Practice Address - Fax:951-652-5547
Is Sole Proprietor?:No
Enumeration Date:2010-05-25
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA122319207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1346569779Medicaid
CACA155032Medicare PIN