Provider Demographics
NPI:1154392348
Name:KHONSARI, ALIREZA (MD)
Entity type:Individual
Prefix:DR
First Name:ALIREZA
Middle Name:
Last Name:KHONSARI
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 1:6119 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804
Mailing Address - Country:US
Mailing Address - Phone:260-432-1568
Mailing Address - Fax:260-432-4969
Practice Address - Street 1:710 NORTH EAST STREET
Practice Address - Street 2:WABASH COUNTY HOSPITAL
Practice Address - City:WABASH
Practice Address - State:IN
Practice Address - Zip Code:46992
Practice Address - Country:US
Practice Address - Phone:260-569-2240
Practice Address - Fax:260-569-2380
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01033004A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN136270GGOtherMEDICARE
IN981270KKMedicare ID - Type Unspecified
B29722Medicare UPIN