Provider Demographics
NPI:1689845588
Name:KHODADADI, OMID (MD)
Entity Type:Individual
Prefix:
First Name:OMID
Middle Name:
Last Name:KHODADADI
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 1:1225 WILSHIRE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-1901
Mailing Address - Country:US
Mailing Address - Phone:213-977-2486
Mailing Address - Fax:
Practice Address - Street 1:1225 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-1901
Practice Address - Country:US
Practice Address - Phone:213-977-2486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101046207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP01497136OtherRAILROAD PTAN