Healthcare Provider Details

I. General information

NPI: 1356536585
Provider Name (Legal Business Name): REZA KHORSAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 09/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 16TH ST STE 309
SANTA MONICA CA
90404-1239
US

IV. Provider business mailing address

1245 16TH ST STE 309
SANTA MONICA CA
90404-1239
US

V. Phone/Fax

Practice location:
  • Phone: 310-319-4371
  • Fax: 310-319-4141
Mailing address:
  • Phone: 310-319-4371
  • Fax: 310-319-4141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA101659
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA101659
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: