Provider Demographics
NPI:1437278603
Name:KHODDAMI, SEYED MOHAMMAD REZA (MD)
Entity Type:Individual
Prefix:
First Name:SEYED
Middle Name:MOHAMMAD REZA
Last Name:KHODDAMI
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 1:5855 OLIVAS PARK DR
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-7672
Mailing Address - Country:US
Mailing Address - Phone:805-667-2801
Mailing Address - Fax:805-667-2865
Practice Address - Street 1:2705 LOMA VISTA RD
Practice Address - Street 2:SUITE 206
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-1581
Practice Address - Country:US
Practice Address - Phone:805-643-4067
Practice Address - Fax:805-643-4587
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1096652088P0231X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA109665OtherCALIFORNIA STATE