Provider Demographics
NPI:1558340034
Name:KHORSANDI, MEHRAN J (MD,)
Entity Type:Individual
Prefix:
First Name:MEHRAN
Middle Name:J
Last Name:KHORSANDI
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 1:8635 W 3RD ST
Mailing Address - Street 2:STE# 695W
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-6101
Mailing Address - Country:US
Mailing Address - Phone:310-967-2140
Mailing Address - Fax:
Practice Address - Street 1:8635 W 3RD ST
Practice Address - Street 2:STE# 695W
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-6101
Practice Address - Country:US
Practice Address - Phone:310-967-2140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61809207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE93751Medicare UPIN