MEDICARE: ARDESHIR KHOSRAVIANI M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	A122319	CA
2	207RN0300X	Nephrology Physician	A122319	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1346569779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ARDESHIR KHOSRAVIANI M.D.

Provider Business Mailing Address
First Line	:	PO BOX 54130
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90054-0130
Country	:	US
Telephone Number	:	951-687-3200
Fax Number	:	951-687-8923

Provider Business Practice Location Address
First Line	:	3989 W STETSON AVE
Second Line	:	SUITE 202
City	:	HEMET
State	:	CA
Zip	:	92545-9695
Country	:	US
Telephone Number	:	951-652-3558
Fax Number	:	951-652-5547

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/25/2010
Last Update Date	:	11/29/2021

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