Provider Demographics
NPI:1306381538
Name:KHADIVI, YASAMAN (RD)
Entity type:Individual
Prefix:
First Name:YASAMAN
Middle Name:
Last Name:KHADIVI
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7378 PEGASUS WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95139-1241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7378 PEGASUS WAY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95139-1241
Practice Address - Country:US
Practice Address - Phone:408-693-0502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-25
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86081191133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered