Provider Demographics
NPI:1477177640
Name:KHOSHPOURI, PEGAH (MD)
Entity Type:Individual
Prefix:
First Name:PEGAH
Middle Name:
Last Name:KHOSHPOURI
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 1:1959 NE PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98195-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 N 1900 E RM 1A071
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0002
Practice Address - Country:US
Practice Address - Phone:801-581-2868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-03
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12439655-12052085R0202X
390200000X
WAMD.MD.612319752085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program