Provider Demographics
NPI:1619985868
Name:KHATAMI, MANOOCHEHR (MD)
Entity Type:Individual
Prefix:
First Name:MANOOCHEHR
Middle Name:
Last Name:KHATAMI
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 1:9834 GENESEE AVE STE 427
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-1264
Mailing Address - Country:US
Mailing Address - Phone:214-734-7140
Mailing Address - Fax:
Practice Address - Street 1:9834 GENESEE AVE STE 427
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1264
Practice Address - Country:US
Practice Address - Phone:214-734-7140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF8781174400000X
CAA375512084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist