Provider Demographics
NPI:1700050689
Name:KHODAVERDIAN, REZA (MD)
Entity Type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:KHODAVERDIAN
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 1:19 HEATHER HILL LN
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-6043
Mailing Address - Country:US
Mailing Address - Phone:801-641-1344
Mailing Address - Fax:760-568-6470
Practice Address - Street 1:39000 BOB HOPE DR STE K108
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-7001
Practice Address - Country:US
Practice Address - Phone:801-641-1344
Practice Address - Fax:760-568-6470
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA127413208600000X, 208G00000X, 208G00000X, 208600000X
MDPENDING208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery