Provider Demographics
NPI:1558477513
Name:KIANI KHOZANI, GHOLAM A (MD)
Entity Type:Individual
Prefix:
First Name:GHOLAM
Middle Name:A
Last Name:KIANI KHOZANI
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:PO BOX 720206
Mailing Address - Street 2:
Mailing Address - City:MCALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:78504-0206
Mailing Address - Country:US
Mailing Address - Phone:956-803-0401
Mailing Address - Fax:956-322-5739
Practice Address - Street 1:5121 N JACKSON RD STE 10
Practice Address - Street 2:
Practice Address - City:MCALLEN
Practice Address - State:TX
Practice Address - Zip Code:78504-6343
Practice Address - Country:US
Practice Address - Phone:956-803-0401
Practice Address - Fax:956-322-5739
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2022-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK6870207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX148513805Medicaid
TX00138HAB8KOtherPTAN
TX45D1006440OtherCLIA
TX148513802Medicaid
TX45D2237106OtherCLIA