Provider Demographics
NPI:1396819645
Name:MALEKI, KHOSROW (MD)
Entity type:Individual
Prefix:MR
First Name:KHOSROW
Middle Name:
Last Name:MALEKI
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 1:917 1ST ST N
Mailing Address - Street 2:UNIT 701
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-7198
Mailing Address - Country:US
Mailing Address - Phone:904-687-5179
Mailing Address - Fax:
Practice Address - Street 1:917 1ST ST N
Practice Address - Street 2:UNIT 701
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-7198
Practice Address - Country:US
Practice Address - Phone:904-687-5179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0026203207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL065167200Medicaid
00047312Medicare Oscar/Certification
FL065167200Medicaid
D55006Medicare UPIN
FLD55006Medicare UPIN