Provider Demographics
NPI:1104871938
Name:KHAVARIAN, CAMERON (MD)
Entity type:Individual
Prefix:DR
First Name:CAMERON
Middle Name:
Last Name:KHAVARIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:CAMERON
Other - Middle Name:
Other - Last Name:KHAVARIAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, INC
Mailing Address - Street 1:320 SUPERIOR AVENUE
Mailing Address - Street 2:SUITE 320
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-2742
Mailing Address - Country:US
Mailing Address - Phone:949-645-8475
Mailing Address - Fax:855-213-1762
Practice Address - Street 1:320 SUPERIOR AVENUE
Practice Address - Street 2:SUITE 320
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-2742
Practice Address - Country:US
Practice Address - Phone:949-645-8475
Practice Address - Fax:855-213-1762
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79842207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
W20689OtherPTAN
1104871938OtherINDIVIDUAL NPI
1528138823OtherGROUP NPI
1528138823OtherGROUP NPI
H92892Medicare UPIN