1558477513 NPI number — GHOLAM A KIANI KHOZANI M.D.

Table of content: GHOLAM A KIANI KHOZANI M.D. (NPI 1558477513)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558477513 NPI number — GHOLAM A KIANI KHOZANI M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIANI KHOZANI
Provider First Name:
GHOLAM
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1558477513
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 720206
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCALLEN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78504-0206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
956-803-0401
Provider Business Mailing Address Fax Number:
956-322-5739

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5121 N JACKSON RD STE 10
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCALLEN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78504-6343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
956-803-0401
Provider Business Practice Location Address Fax Number:
956-322-5739
Provider Enumeration Date:
08/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  K6870 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 148513805 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00138HAB8K . This is a "PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 45D1006440 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 148513802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 45D2237106 . This is a "CLIA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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