Provider Demographics
NPI:1811147531
Name:KEYVAN ESMAEILI M D INC
Entity type:Organization
Organization Name:KEYVAN ESMAEILI M D INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEYVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ESMAEILI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-373-0881
Mailing Address - Street 1:PO BOX 1895
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92033-1895
Mailing Address - Country:US
Mailing Address - Phone:714-373-0881
Mailing Address - Fax:
Practice Address - Street 1:215 S HICKORY ST STE 118
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4304
Practice Address - Country:US
Practice Address - Phone:714-373-0881
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-30
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72887208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A728870Medicaid
CA00A728870Medicaid