Provider Demographics
NPI:1881030484
Name:KHASHAYAR MOHEBALI MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:KHASHAYAR MOHEBALI MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KHASHAYAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MOHEBALI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-412-4921
Mailing Address - Street 1:548 COLUMBIA CREEK DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-5611
Mailing Address - Country:US
Mailing Address - Phone:925-556-4336
Mailing Address - Fax:925-556-9270
Practice Address - Street 1:21 TAMAL VISTA BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1130
Practice Address - Country:US
Practice Address - Phone:415-927-7660
Practice Address - Fax:415-927-7663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA94434208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty