Healthcare Provider Details

I. General information

NPI: 1235123142
Provider Name (Legal Business Name): KHOSROW MEHRANY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MARK MEHRANY M.D.

II. Dates (important events)

Enumeration Date: 09/07/2005
Last Update Date: 06/21/2021
Certification Date: 12/04/2020
Deactivation Date: 03/25/2006
Reactivation Date: 04/13/2006

III. Provider practice location address

1729 TULLY RD STE 9
MODESTO CA
95350-4081
US

IV. Provider business mailing address

64 MARIPOSA AVE
LOS GATOS CA
95030-4317
US

V. Phone/Fax

Practice location:
  • Phone: 209-338-7758
  • Fax: 209-554-0311
Mailing address:
  • Phone: 209-338-7758
  • Fax: 209-554-0311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA87519
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: