Healthcare Provider Details

I. General information

NPI: 1881030484
Provider Name (Legal Business Name): KHASHAYAR MOHEBALI MD A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 05/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 TAMAL VISTA BLVD SUITE 103
CORTE MADERA CA
94925-1130
US

IV. Provider business mailing address

548 COLUMBIA CREEK DR
SAN RAMON CA
94582-5611
US

V. Phone/Fax

Practice location:
  • Phone: 415-927-7660
  • Fax: 415-927-7663
Mailing address:
  • Phone: 925-556-4336
  • Fax: 925-556-9270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA94434
License Number StateCA

VIII. Authorized Official

Name: DR. KHASHAYAR MOHEBALI
Title or Position: PRESIDENT
Credential: MD
Phone: 415-412-4921