Healthcare Provider Details

I. General information

NPI: 1003959776
Provider Name (Legal Business Name): SOHEILA KHAJAVI, M.D. MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32118 PASEO ADELANTO SUITE 6AR
SAN JUAN CAPISTRANO CA
92675-3627
US

IV. Provider business mailing address

32118 PASEO ADELANTO SUITE 6AR
SAN JUAN CAPISTRANO CA
92675-3627
US

V. Phone/Fax

Practice location:
  • Phone: 949-240-1319
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA44214
License Number StateCA

VIII. Authorized Official

Name: DR. SOHEILA KHAJAVI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 949-240-1319