Provider Demographics
NPI:1912384611
Name:KHOSRAVI, GOHAR (MD)
Entity Type:Individual
Prefix:
First Name:GOHAR
Middle Name:
Last Name:KHOSRAVI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 N KRAEMER BLVD UNIT 171
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92871-1408
Mailing Address - Country:US
Mailing Address - Phone:657-341-4422
Mailing Address - Fax:
Practice Address - Street 1:11401 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CA
Practice Address - Zip Code:90650-2015
Practice Address - Country:US
Practice Address - Phone:949-331-9781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2023-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1584612084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program