Provider Demographics
NPI:1306874714
Name:KHONSARI, HAMIDREZA M (MD)
Entity type:Individual
Prefix:DR
First Name:HAMIDREZA
Middle Name:M
Last Name:KHONSARI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3903 LONE TREE WAY STE 104
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-6251
Mailing Address - Country:US
Mailing Address - Phone:925-755-1255
Mailing Address - Fax:925-755-1259
Practice Address - Street 1:3903 LONE TREE WAY
Practice Address - Street 2:SUITE 104
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-6249
Practice Address - Country:US
Practice Address - Phone:925-755-1255
Practice Address - Fax:925-755-1259
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2025-03-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAA486070207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE22865Medicare UPIN