Provider Demographics
NPI:1619959772
Name:KHAGHANY, KIANOUSH (MD)
Entity Type:Individual
Prefix:MR
First Name:KIANOUSH
Middle Name:
Last Name:KHAGHANY
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 1:1046 N MONROE ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-3113
Mailing Address - Country:US
Mailing Address - Phone:734-457-9034
Mailing Address - Fax:734-457-9037
Practice Address - Street 1:1046 N MONROE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-3113
Practice Address - Country:US
Practice Address - Phone:734-457-9034
Practice Address - Fax:734-457-9037
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIKK072919207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1605802182OtherBLUE CROSS BLUE SHIELD
MI16945OtherMCARE
MI20630OtherHEALTHPLAN OF MICHIGAN
MI7626369OtherAETNA
MI04232OtherPARAMOUNT
MI1605802182OtherBLUE CARE NETWORK
MIP00215065OtherRAILROAD MEDICARE
MI04232OtherPARAMOUNT
MI1605802182OtherBLUE CROSS BLUE SHIELD
H81507Medicare UPIN