Provider Demographics
NPI:1548232226
Name:YEZDANI, KHAJA (MD)
Entity Type:Individual
Prefix:DR
First Name:KHAJA
Middle Name:
Last Name:YEZDANI
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 1:1602 NEWPORT GAP PIKE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-6208
Mailing Address - Country:US
Mailing Address - Phone:302-633-5840
Mailing Address - Fax:302-633-5844
Practice Address - Street 1:191 CHRISTIANA RD
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:DE
Practice Address - Zip Code:19720-3024
Practice Address - Country:US
Practice Address - Phone:302-322-1794
Practice Address - Fax:302-322-3498
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0001878207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000015490Medicaid
DE1000015490Medicaid
DE761651Medicare ID - Type Unspecified