Provider Demographics
NPI:1780798702
Name:MONTAZERI, KHASHAYAR (MD)
Entity type:Individual
Prefix:DR
First Name:KHASHAYAR
Middle Name:
Last Name:MONTAZERI
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:PO BOX 9017
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-0917
Mailing Address - Country:US
Mailing Address - Phone:925-952-2828
Mailing Address - Fax:925-952-2850
Practice Address - Street 1:1220 ROSSMOOR PKWY
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94595-2501
Practice Address - Country:US
Practice Address - Phone:925-947-3393
Practice Address - Fax:925-947-3396
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77713207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00938334OtherRAILROAD MEDICARE
CA00A777130Medicaid
CAP00938334OtherRAILROAD MEDICARE
CA00A777130Medicaid