Healthcare Provider Details

I. General information

NPI: 1174744387
Provider Name (Legal Business Name): ATOSA MAHJOORY-KHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

163 HAMPTON POINT DR SUITE 1 & 2
ST AUGUSTINE FL
32092-3059
US

IV. Provider business mailing address

163 HAMPTON POINT DR SUITE 1 & 2
ST AUGUSTINE FL
32092-3059
US

V. Phone/Fax

Practice location:
  • Phone: 904-230-5590
  • Fax: 904-230-5591
Mailing address:
  • Phone: 904-230-5590
  • Fax: 904-230-5591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN 14201
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: