Provider Demographics
NPI:1407868789
Name:KHOSRAVI, VISTA S (MD)
Entity Type:Individual
Prefix:
First Name:VISTA
Middle Name:S
Last Name:KHOSRAVI
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 1:1606 MONTELLANO CT
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-4833
Mailing Address - Country:US
Mailing Address - Phone:408-927-9938
Mailing Address - Fax:
Practice Address - Street 1:80 GREAT OAKS BLVD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1310
Practice Address - Country:US
Practice Address - Phone:408-363-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG80120207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology