Provider Demographics
NPI:1699719963
Name:KHOSHYOMN, SAMI (MD)
Entity type:Individual
Prefix:DR
First Name:SAMI
Middle Name:
Last Name:KHOSHYOMN
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:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:
Practice Address - Street 1:1965 S FREMONT AVE
Practice Address - Street 2:SUITE 130
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2201
Practice Address - Country:US
Practice Address - Phone:417-820-5150
Practice Address - Fax:417-820-5155
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005000362207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO207309600Medicaid
MO2005000362Medicare UPIN
MO932593268Medicare PIN