Provider Demographics
NPI:1497449060
Name:KHOSTOVAN, ELAHEH (RD)
Entity Type:Individual
Prefix:
First Name:ELAHEH
Middle Name:
Last Name:KHOSTOVAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1673 LOGAN AVE UNIT 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92113-1004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1673 LOGAN AVE UNIT 2
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92113-1004
Practice Address - Country:US
Practice Address - Phone:415-308-7464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-06
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered