Provider Demographics
NPI:1306990387
Name:KHALVATI - KHOSRAVI, NOOSHAZAR (MD)
Entity type:Individual
Prefix:DR
First Name:NOOSHAZAR
Middle Name:
Last Name:KHALVATI - KHOSRAVI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NOOSHAZAR
Other - Middle Name:
Other - Last Name:KHALVATI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:4123 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE E.
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4371
Mailing Address - Country:US
Mailing Address - Phone:904-731-5437
Mailing Address - Fax:904-733-6776
Practice Address - Street 1:4123 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE E.
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4371
Practice Address - Country:US
Practice Address - Phone:904-731-5437
Practice Address - Fax:904-733-6776
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME41780174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
15839OtherBCBS
D52753Medicare UPIN