Provider Demographics
NPI:1932399482
Name:KHAVARI, ANDREW REZA (MD)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:REZA
Last Name:KHAVARI
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:PO BOX 933421
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0039
Mailing Address - Country:US
Mailing Address - Phone:937-641-3000
Mailing Address - Fax:
Practice Address - Street 1:1 CHILDRENS PLZ
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45404-1815
Practice Address - Country:US
Practice Address - Phone:937-641-4040
Practice Address - Fax:937-641-3066
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2023-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0914092084P0804X
OH35-0914092084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3047063Medicaid
OH3047063Medicaid
OH000000659792OtherANTHEM
OH$$$$$$$$$00OtherBWC
OH3047063Medicaid