Provider Demographics
NPI:1295066397
Name:KHAVARI, ROSE (MD)
Entity type:Individual
Prefix:DR
First Name:ROSE
Middle Name:
Last Name:KHAVARI
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 1:6560 FANNIN ST STE 2100
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2769
Mailing Address - Country:US
Mailing Address - Phone:713-441-6455
Mailing Address - Fax:
Practice Address - Street 1:6560 FANNIN ST STE 2100
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2769
Practice Address - Country:US
Practice Address - Phone:713-441-6455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-29
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXN7627208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8DK892OtherBLUE CROSS BLUE SHIELD
TX314980902Medicaid
TX1295066397OtherBLUE CROSS BLUE SHIELD
TX314980901Medicaid
TX314980901Medicaid
TX308711YMVQMedicare PIN
TX314980902Medicaid