Provider Demographics
NPI:1295944957
Name:KHOSROW DAVACHI MD PC
Entity type:Organization
Organization Name:KHOSROW DAVACHI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KHOSROW
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVACHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:301-868-7121
Mailing Address - Street 1:7700 OLD BRANCH AVE STE D203
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MD
Mailing Address - Zip Code:20735-1611
Mailing Address - Country:US
Mailing Address - Phone:301-868-7121
Mailing Address - Fax:301-868-7968
Practice Address - Street 1:7700 OLD BRANCH AVE STE D203
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-1611
Practice Address - Country:US
Practice Address - Phone:301-868-7121
Practice Address - Fax:301-877-1934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0025640207RN0300X
DCMD8172207RN0300X, 207RN0300X
MDD0055120207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
4050444OtherAETNA
417465OtherMAMSI
VA097999OtherANTHEM BX
MD05722Medicaid
DC0771 0001OtherBLUE CHOICE
DC4954Medicaid
MDCH8837OtherRAILROAD MEDICARE
DC048343500Medicaid
DC10094Medicaid
175743OtherMEDICARE
MD27555Medicaid
DCCH8837OtherRAILROAD MEDICARE
DC05722Medicaid
DC0771 0001OtherBX DC
MD30859001OtherBX MARYLAND
0734041012OtherCIGNA
MD205102800Medicaid
MD30859001OtherBX MARYLAND
4050444OtherAETNA
MD205102800Medicaid