Provider Demographics
NPI:1831170869
Name:KHADEMI, JAMSHID (MD)
Entity type:Individual
Prefix:
First Name:JAMSHID
Middle Name:
Last Name:KHADEMI
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 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:1800 MULBERRY ST.
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18510-6800
Practice Address - Country:US
Practice Address - Phone:570-703-8259
Practice Address - Fax:570-703-7250
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD064062L207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01716353Medicaid
PA050083939OtherRR MEDICARE
G80046Medicare UPIN
PA01716353Medicaid
PA050083939OtherRR MEDICARE