Provider Demographics
NPI:1710946892
Name:POURKAVOOS, KHOSRO
Entity Type:Individual
Prefix:DR
First Name:KHOSRO
Middle Name:
Last Name:POURKAVOOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-2314
Mailing Address - Country:US
Mailing Address - Phone:860-676-0090
Mailing Address - Fax:
Practice Address - Street 1:35 NOD RD
Practice Address - Street 2:SUITE 205
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3826
Practice Address - Country:US
Practice Address - Phone:860-676-0090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-18
Last Update Date:2010-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039709207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine