Provider Demographics
NPI:1285620690
Name:KHOSHOO, VIKRAM (MD)
Entity type:Individual
Prefix:DR
First Name:VIKRAM
Middle Name:
Last Name:KHOSHOO
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 1:1111 MEDICAL CENTER BLVD
Mailing Address - Street 2:SOUTH 650, ATTN: HEIDI GWINN
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3151
Mailing Address - Country:US
Mailing Address - Phone:504-349-1297
Mailing Address - Fax:504-349-1146
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE SOUTH 650
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3151
Practice Address - Country:US
Practice Address - Phone:504-349-6504
Practice Address - Fax:504-349-6528
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08776R2080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1922510Medicaid
LAF02765Medicare UPIN
LA5N725Medicare ID - Type Unspecified