1598176448 NPI number — DR. DEREK A KHORSAND MD

Table of content: DR. DEREK A KHORSAND MD (NPI 1598176448)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598176448 NPI number — DR. DEREK A KHORSAND MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHORSAND
Provider First Name:
DEREK
Provider Middle Name:
A
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:
1598176448
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/25/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
KOOTENAI OUTPATIENT IMAGING
Provider Second Line Business Mailing Address:
700 W IRONWOOD DR, SUITE 175
Provider Business Mailing Address City Name:
COEUR D'ALENE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-625-6300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
KOOTENAI HEALTH
Provider Second Line Business Practice Location Address:
2003 KOOTENAI WAY
Provider Business Practice Location Address City Name:
COEUR D'ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-625-6361
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/14/2014

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:  M-15066 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0204X , with the licence number: M-15066 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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