Healthcare Provider Details

I. General information

NPI: 1780379594
Provider Name (Legal Business Name): MEHRDAD KHODADOOSTAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2023
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18650 MACARTHUR BLVD STE 450
IRVINE CA
92612-1253
US

IV. Provider business mailing address

19528 VENTURA BLVD APT 711
TARZANA CA
91356-2917
US

V. Phone/Fax

Practice location:
  • Phone: 949-570-7750
  • Fax:
Mailing address:
  • Phone: 310-245-8221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE6264
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: