Provider Demographics
NPI:1124229554
Name:KHOSROW MAHDAVI, M.D., INC
Entity type:Organization
Organization Name:KHOSROW MAHDAVI, M.D., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KHOSROW
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHDAVI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-642-8566
Mailing Address - Street 1:4000 W COAST HWY
Mailing Address - Street 2:SUITE 3D
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-2695
Mailing Address - Country:US
Mailing Address - Phone:949-642-8566
Mailing Address - Fax:949-642-0746
Practice Address - Street 1:4000 W COAST HWY
Practice Address - Street 2:SUITE 3D
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-2695
Practice Address - Country:US
Practice Address - Phone:949-642-8566
Practice Address - Fax:949-642-0746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33589261QI0500X, 261QX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
Not Answered261QX0200XAmbulatory Health Care FacilitiesClinic/CenterOncology