Provider Demographics
NPI:1720041858
Name:KHORRAM, OMID (MD)
Entity Type:Individual
Prefix:
First Name:OMID
Middle Name:
Last Name:KHORRAM
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 1:23550 HAWTHORNE BLVD
Mailing Address - Street 2:STE. 210
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-4731
Mailing Address - Country:US
Mailing Address - Phone:310-378-7445
Mailing Address - Fax:310-378-7427
Practice Address - Street 1:23550 HAWTHORNE BLVD
Practice Address - Street 2:STE. 210
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4731
Practice Address - Country:US
Practice Address - Phone:310-378-7445
Practice Address - Fax:310-378-7427
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA48465207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A484650Medicaid
CA00A484650Medicaid
CAF55838Medicare UPIN
CAWA48465CMedicare ID - Type UnspecifiedPPIN
CAWA48465EMedicare ID - Type UnspecifiedPPIN