Healthcare Provider Details

I. General information

NPI: 1124229554
Provider Name (Legal Business Name): KHOSROW MAHDAVI, M.D., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 W COAST HWY SUITE 3D
NEWPORT BEACH CA
92663-2695
US

IV. Provider business mailing address

4000 W COAST HWY SUITE 3D
NEWPORT BEACH CA
92663-2695
US

V. Phone/Fax

Practice location:
  • Phone: 949-642-8566
  • Fax: 949-642-0746
Mailing address:
  • Phone: 949-642-8566
  • Fax: 949-642-0746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License NumberA33589
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QX0200X
TaxonomyOncology Clinic/Center
License NumberA33589
License Number StateCA

VIII. Authorized Official

Name: DR. KHOSROW MAHDAVI
Title or Position: PRESIDENT
Credential: MD
Phone: 949-642-8566