Provider Demographics
NPI:1215982186
Name:BAHRANI, KHOSROW (MD)
Entity type:Individual
Prefix:
First Name:KHOSROW
Middle Name:
Last Name:BAHRANI
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 1:3111 MAPLEWOOD AVE
Mailing Address - Street 2:SUITE # 101
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3906
Mailing Address - Country:US
Mailing Address - Phone:336-768-2162
Mailing Address - Fax:336-760-4119
Practice Address - Street 1:3111 MAPLEWOOD AVE
Practice Address - Street 2:SUITE # 101
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3906
Practice Address - Country:US
Practice Address - Phone:336-768-2162
Practice Address - Fax:336-760-4119
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC183532084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC12493OtherBCBS
NC85227Medicare UPIN
NC201562Medicare ID - Type Unspecified