Provider Demographics
NPI:1356342521
Name:KHODABANDELOU, MOHAMMAD (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:
Last Name:KHODABANDELOU
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 1:6 SAINT ANDREWS CROSSOVER
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-2403
Mailing Address - Country:US
Mailing Address - Phone:410-987-5692
Mailing Address - Fax:410-355-3449
Practice Address - Street 1:614 E PATAPSCO AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21225-1933
Practice Address - Country:US
Practice Address - Phone:410-355-0074
Practice Address - Fax:410-355-3449
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD14375173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDB66676Medicare UPIN
MD4873Medicare ID - Type Unspecified