Provider Demographics
NPI:1467411488
Name:KHOJASTEH, ALI (MD)
Entity Type:Individual
Prefix:DR
First Name:ALI
Middle Name:
Last Name:KHOJASTEH
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 104240
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65110-4240
Mailing Address - Country:US
Mailing Address - Phone:573-893-6404
Mailing Address - Fax:573-893-6505
Practice Address - Street 1:1241 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-6023
Practice Address - Country:US
Practice Address - Phone:573-893-6404
Practice Address - Fax:573-893-6505
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR9764207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO201083326Medicaid
MO110080769OtherRAILROAD MEDICARE
MO110037534OtherRAILROAD MEDICARE
MO110037534OtherRAILROAD MEDICARE
MO001012476Medicare PIN