Provider Demographics
NPI:1356335277
Name:KHANLOU, HOMAYOON (MD)
Entity type:Individual
Prefix:
First Name:HOMAYOON
Middle Name:
Last Name:KHANLOU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6360 WILSHIRE BLVD
Mailing Address - Street 2:414
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048
Mailing Address - Country:US
Mailing Address - Phone:323-397-0897
Mailing Address - Fax:323-655-1377
Practice Address - Street 1:6360 WILSHIRE BLVD
Practice Address - Street 2:414
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048
Practice Address - Country:US
Practice Address - Phone:323-397-0897
Practice Address - Fax:323-655-1377
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA66631207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A666310Medicaid
H01080Medicare UPIN