Provider Demographics
NPI:1548573215
Name:KHODADOUST, MICHAEL SIAVASH (MD/PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:SIAVASH
Last Name:KHODADOUST
Suffix:
Gender:M
Credentials:MD/PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 BLAKE WILBUR DR
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94304-2205
Mailing Address - Country:US
Mailing Address - Phone:650-498-6000
Mailing Address - Fax:
Practice Address - Street 1:875 BLAKE WILBUR DR
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-2205
Practice Address - Country:US
Practice Address - Phone:650-498-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA118295207RH0003X, 207R00000X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
No207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine