Healthcare Provider Details

I. General information

NPI: 1164403929
Provider Name (Legal Business Name): MANOUCHEHR KHANDADASH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 01/27/2026
Certification Date: 01/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38440 5TH ST W
PALMDALE CA
93551-4498
US

IV. Provider business mailing address

38440 5TH ST W
PALMDALE CA
93551-4498
US

V. Phone/Fax

Practice location:
  • Phone: 661-575-2725
  • Fax:
Mailing address:
  • Phone: 661-214-7718
  • Fax: 661-214-7719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number216995-1
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC51781
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: