Provider Demographics
NPI:1598176448
Name:KHORSAND, DEREK A (MD)
Entity Type:Individual
Prefix:DR
First Name:DEREK
Middle Name:A
Last Name:KHORSAND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:KOOTENAI OUTPATIENT IMAGING
Mailing Address - Street 2:700 W IRONWOOD DR, SUITE 175
Mailing Address - City:COEUR D'ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-625-6300
Mailing Address - Fax:
Practice Address - Street 1:KOOTENAI HEALTH
Practice Address - Street 2:2003 KOOTENAI WAY
Practice Address - City:COEUR D'ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-625-6361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-14
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDM-150662085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology