Healthcare Provider Details

I. General information

NPI: 1275536773
Provider Name (Legal Business Name): KHOSROW MAHDAVI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 11/15/2023
Certification Date: 11/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 NEWPORT BLVD STE 400
COSTA MESA CA
92627-3786
US

IV. Provider business mailing address

200 S MANCHESTER AVE STE 300
ORANGE CA
92868-3219
US

V. Phone/Fax

Practice location:
  • Phone: 949-999-2400
  • Fax:
Mailing address:
  • Phone: 714-456-2986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA33589
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberA33589
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberA33589
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberA33589
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: