Provider Demographics
NPI:1881696060
Name:KHOUZAM, SAMEH N (MD)
Entity type:Individual
Prefix:
First Name:SAMEH
Middle Name:N
Last Name:KHOUZAM
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 1:4160 LITTLE YORK RD STE 20
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-5803
Mailing Address - Country:US
Mailing Address - Phone:937-454-9527
Mailing Address - Fax:937-454-9532
Practice Address - Street 1:4160 LITTLE YORK RD STE 20
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414
Practice Address - Country:US
Practice Address - Phone:937-454-9527
Practice Address - Fax:937-454-9532
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH084219207RC0000X, 207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2495643Medicaid
OH2495643Medicaid
OHH053240Medicare PIN
OHKH4132411Medicare ID - Type Unspecified