Provider Demographics
NPI:1740287887
Name:DASTUR, KHURSHED J (MD)
Entity type:Individual
Prefix:
First Name:KHURSHED
Middle Name:J
Last Name:DASTUR
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 1:1100 N TUSTIN AVE
Mailing Address - Street 2:UNIT A
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3509
Mailing Address - Country:US
Mailing Address - Phone:714-835-6055
Mailing Address - Fax:714-285-9084
Practice Address - Street 1:1100 N TUSTIN AVE
Practice Address - Street 2:UNIT A
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-3509
Practice Address - Country:US
Practice Address - Phone:714-835-6055
Practice Address - Fax:714-285-9084
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD033846L2085R0202X
CAC560862085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA142495G89Medicare PIN
B39300Medicare UPIN
CACB212996Medicare PIN