Provider Demographics
NPI:1700164282
Name:PERSAUD, KHAMRANIE N (MD)
Entity Type:Individual
Prefix:DR
First Name:KHAMRANIE
Middle Name:N
Last Name:PERSAUD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KHAMRANIE
Other - Middle Name:
Other - Last Name:BHAGROO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1840 MESQUITE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LAKE HAVASU CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86403-5771
Mailing Address - Country:US
Mailing Address - Phone:928-453-8500
Mailing Address - Fax:
Practice Address - Street 1:1840 MESQUITE AVE STE B
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403
Practice Address - Country:US
Practice Address - Phone:928-453-8500
Practice Address - Fax:928-453-3660
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
AZ46531207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ718043Medicaid
AZZ154677Medicare PIN