Provider Demographics
NPI:1013102904
Name:KAVOUSSI, KEIKHOSROW M (MD)
Entity Type:Individual
Prefix:DR
First Name:KEIKHOSROW
Middle Name:M
Last Name:KAVOUSSI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4303 JAMES CASEY ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78745
Mailing Address - Country:US
Mailing Address - Phone:512-444-1414
Mailing Address - Fax:512-444-5621
Practice Address - Street 1:4303 JAMES CASEY ST
Practice Address - Street 2:SUITE A
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78745
Practice Address - Country:US
Practice Address - Phone:512-444-1414
Practice Address - Fax:512-444-5621
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2406207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
Provider Identifiers
StateIdentifier IDID TypeIssuer
8A0482Medicare PIN
TXC17741Medicare UPIN