Provider Demographics
NPI:1720005515
Name:DANESHMAND, KHASHAYAR ALEX (DO)
Entity Type:Individual
Prefix:DR
First Name:KHASHAYAR
Middle Name:ALEX
Last Name:DANESHMAND
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-6001
Mailing Address - Fax:
Practice Address - Street 1:9981 HEALTHPARK DRIVE
Practice Address - Street 2:
Practice Address - City:FT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908
Practice Address - Country:US
Practice Address - Phone:239-343-5651
Practice Address - Fax:239-343-5652
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS98022080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275563700Medicaid
FL275563700Medicaid