1154392348 NPI number — DR. ALIREZA KHONSARI MD

Table of content: DR. ALIREZA KHONSARI MD (NPI 1154392348)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154392348 NPI number — DR. ALIREZA KHONSARI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHONSARI
Provider First Name:
ALIREZA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1154392348
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6119 W JEFFERSON BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-432-1568
Provider Business Mailing Address Fax Number:
260-432-4969

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
710 NORTH EAST STREET
Provider Second Line Business Practice Location Address:
WABASH COUNTY HOSPITAL
Provider Business Practice Location Address City Name:
WABASH
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46992
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-569-2240
Provider Business Practice Location Address Fax Number:
260-569-2380
Provider Enumeration Date:
01/27/2006

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: 2085R0202X , with the licence number:  01033004A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 136270GG . This is a "MEDICARE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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