Provider Demographics
NPI:1316987050
Name:KHORSANDI, MOEZ (DO, FACOS)
Entity type:Individual
Prefix:DR
First Name:MOEZ
Middle Name:
Last Name:KHORSANDI
Suffix:
Gender:M
Credentials:DO, FACOS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 408
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4810
Mailing Address - Country:US
Mailing Address - Phone:213-482-2910
Mailing Address - Fax:
Practice Address - Street 1:1245 WILSHIRE BLVD
Practice Address - Street 2:SUITE 408
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4810
Practice Address - Country:US
Practice Address - Phone:213-482-2910
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6773208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH12011Medicare UPIN