Provider Demographics
NPI:1376049528
Name:KHAYYAT KHOLGHI, MAEDEH (DO)
Entity type:Individual
Prefix:DR
First Name:MAEDEH
Middle Name:
Last Name:KHAYYAT KHOLGHI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:MAEDEH
Other - Middle Name:
Other - Last Name:KHOLGHI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3098
Mailing Address - Country:US
Mailing Address - Phone:503-494-8211
Mailing Address - Fax:
Practice Address - Street 1:18700 N 64TH DR STE 301
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-7114
Practice Address - Country:US
Practice Address - Phone:602-841-0741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-04
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ011221207RC0000X
NM390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program