Provider Demographics
NPI:1487612560
Name:KHONSARI, FERAIDOUN FRED (MD)
Entity type:Individual
Prefix:DR
First Name:FERAIDOUN
Middle Name:FRED
Last Name:KHONSARI
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 1:1140 W LA VETA AVE
Mailing Address - Street 2:SUITE 605
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4225
Mailing Address - Country:US
Mailing Address - Phone:714-547-7457
Mailing Address - Fax:714-547-6202
Practice Address - Street 1:1140 W LA VETA AVE
Practice Address - Street 2:SUITE 605
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4225
Practice Address - Country:US
Practice Address - Phone:714-547-7457
Practice Address - Fax:714-547-6202
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31098208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A310980Medicaid
CAB50158Medicare UPIN
CAA31098Medicare ID - Type Unspecified