Provider Demographics
NPI:1215990932
Name:KHORSANDI, JAHANYAR (MD)
Entity type:Individual
Prefix:DR
First Name:JAHANYAR
Middle Name:
Last Name:KHORSANDI
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 1:209 CHAMPAGNE BLVD.
Mailing Address - Street 2:
Mailing Address - City:BREAUX BRIDGE
Mailing Address - State:LA
Mailing Address - Zip Code:70517-3448
Mailing Address - Country:US
Mailing Address - Phone:337-332-0222
Mailing Address - Fax:337-332-1102
Practice Address - Street 1:209 CHAMPAGNE BLVD.
Practice Address - Street 2:
Practice Address - City:BREAUX BRIDGE
Practice Address - State:LA
Practice Address - Zip Code:70517-3448
Practice Address - Country:US
Practice Address - Phone:337-332-0222
Practice Address - Fax:337-332-1102
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1484687Medicaid
5E485CJ59Medicare PIN
LAG92005Medicare UPIN