Provider Demographics
NPI:1215962063
Name:MEHDI KHORSANDI MD INC.
Entity type:Organization
Organization Name:MEHDI KHORSANDI MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MEHDI
Authorized Official - Middle Name:
Authorized Official - Last Name:KHORSANDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-500-1676
Mailing Address - Street 1:1510 S CENTRAL AVE
Mailing Address - Street 2:620
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91204-2500
Mailing Address - Country:US
Mailing Address - Phone:818-500-1676
Mailing Address - Fax:818-500-8360
Practice Address - Street 1:1510 S CENTRAL AVE
Practice Address - Street 2:620
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2500
Practice Address - Country:US
Practice Address - Phone:818-500-1676
Practice Address - Fax:818-500-8360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52802207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A528020Medicaid
CAG05782Medicare UPIN
CAW21459Medicare PIN
CAA52802AMedicare PIN