Provider Demographics
NPI:1184729287
Name:MATT R KHOSHNEVIS MD PA
Entity type:Organization
Organization Name:MATT R KHOSHNEVIS MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MATT
Authorized Official - Middle Name:R
Authorized Official - Last Name:KHOSHNEVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:713-850-1190
Mailing Address - Street 1:PO BOX 540088
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77254-0088
Mailing Address - Country:US
Mailing Address - Phone:713-850-1190
Mailing Address - Fax:713-850-1327
Practice Address - Street 1:4201 GARTH RD STE 318
Practice Address - Street 2:
Practice Address - City:BAYTOWN
Practice Address - State:TX
Practice Address - Zip Code:77521-3156
Practice Address - Country:US
Practice Address - Phone:281-837-6300
Practice Address - Fax:281-422-5959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00567WMedicare PIN