Provider Demographics
NPI:1194169011
Name:MASOUD KHORSAND-SAHBAIE, MD PA
Entity type:Organization
Organization Name:MASOUD KHORSAND-SAHBAIE, MD PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS SYSTEMS/CREDENTIALING MGR
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:COTTRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:575-627-9508
Mailing Address - Street 1:PO BOX 1574
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-1574
Mailing Address - Country:US
Mailing Address - Phone:575-627-9508
Mailing Address - Fax:877-749-7764
Practice Address - Street 1:402 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5247
Practice Address - Country:US
Practice Address - Phone:575-627-9500
Practice Address - Fax:575-627-9535
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MASOUD KHORSAND-SAHBAIE, MD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-04-22
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2011-0207207Q00000X
NMMD2012-0215207R00000X
NMMD2009-0514207R00000X
NM89-280207R00000X
NMCNP-01000363L00000X
NMCNP-01933363LF0000X
NMCNP-02125363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMZ2565Medicaid
NMZ2565Medicaid