Provider Demographics
NPI:1205175775
Name:KHOSRO VAHID, M.D. A MEDICAL CORPORATION
Entity type:Organization
Organization Name:KHOSRO VAHID, M.D. A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:KHOSRO
Authorized Official - Middle Name:
Authorized Official - Last Name:VAHID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:213-304-3742
Mailing Address - Street 1:2121 S SAN PEDRO ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90011-1160
Mailing Address - Country:US
Mailing Address - Phone:213-742-0300
Mailing Address - Fax:213-746-0044
Practice Address - Street 1:2121 S SAN PEDRO ST
Practice Address - Street 2:SUITE E
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90011-1160
Practice Address - Country:US
Practice Address - Phone:213-742-0300
Practice Address - Fax:213-746-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42627207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A426270Medicaid
CA00A426270Medicaid
CAA42627Medicare PIN