Provider Demographics
NPI:1356536585
Name:KHORSAN, REZA (MD)
Entity type:Individual
Prefix:
First Name:REZA
Middle Name:
Last Name:KHORSAN
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 1:1245 16TH ST STE 309
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1239
Mailing Address - Country:US
Mailing Address - Phone:310-319-4371
Mailing Address - Fax:310-319-4141
Practice Address - Street 1:1245 16TH ST STE 309
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1239
Practice Address - Country:US
Practice Address - Phone:310-319-4371
Practice Address - Fax:310-319-4141
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA101659207RN0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1356536585Medicaid
CADZ908YMedicare PIN