Healthcare Provider Details

I. General information

NPI: 1457062531
Provider Name (Legal Business Name): MR. KHASHAYAR GHAZANFARI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2022
Last Update Date: 12/08/2022
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 FOREST AVE
SAN JOSE CA
95128-1471
US

IV. Provider business mailing address

4030 E MORADA LN APT 4205
STOCKTON CA
95212-1641
US

V. Phone/Fax

Practice location:
  • Phone: 408-947-2500
  • Fax:
Mailing address:
  • Phone: 209-409-2619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: