Healthcare Provider Details

I. General information

NPI: 1770144016
Provider Name (Legal Business Name): KHASHAYAR EBRAHIMZADEH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 W HOBSONWAY
BLYTHE CA
92225-1479
US

IV. Provider business mailing address

1415 W HOBSONWAY
BLYTHE CA
92225-1479
US

V. Phone/Fax

Practice location:
  • Phone: 760-922-4981
  • Fax:
Mailing address:
  • Phone: 760-922-4981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number4351045098
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA176374
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: