Provider Demographics
NPI:1790515963
Name:KHOSRAVI-HAFSHEJANI, TOURAJ (MD, FRCPC)
Entity type:Individual
Prefix:
First Name:TOURAJ
Middle Name:
Last Name:KHOSRAVI-HAFSHEJANI
Suffix:
Gender:M
Credentials:MD, FRCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 S BROAD ST APT 642
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-3665
Mailing Address - Country:US
Mailing Address - Phone:604-842-4734
Mailing Address - Fax:
Practice Address - Street 1:3400 CIVIC CENTER BLVD FL 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-5161
Practice Address - Country:US
Practice Address - Phone:215-316-5151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-03
Last Update Date:2024-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD484162207NI0002X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology