Provider Demographics
NPI:1780884395
Name:KHODABAKHSH, DANIEL
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:KHODABAKHSH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8143 CREBS AVE
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-1204
Mailing Address - Country:US
Mailing Address - Phone:415-336-2277
Mailing Address - Fax:
Practice Address - Street 1:1600 W AVENUE J
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2814
Practice Address - Country:US
Practice Address - Phone:661-726-6225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-21
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA106419207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine