Provider Demographics
NPI:1487735692
Name:SADRIEH, KHOSROW (MD)
Entity type:Individual
Prefix:DR
First Name:KHOSROW
Middle Name:
Last Name:SADRIEH
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 1:4910 VAN NUYS BLVD
Mailing Address - Street 2:110
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403-1782
Mailing Address - Country:US
Mailing Address - Phone:818-986-8215
Mailing Address - Fax:818-986-9582
Practice Address - Street 1:4910 VAN NUYS BLVD
Practice Address - Street 2:110
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1782
Practice Address - Country:US
Practice Address - Phone:818-986-8215
Practice Address - Fax:818-986-9582
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29572174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ48958ZOtherBLUE SHIELD PROVIDER #
CAZZZ97621ZOtherBLUE CROSS PROVIDER #
CA00A295720Medicaid
CAA87242Medicare UPIN
CA00A295720Medicaid