Healthcare Provider Details

I. General information

NPI: 1841485695
Provider Name (Legal Business Name): ALI KHODABANDEH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 02/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL ROAD STE. 2A
LEOMINSTER MA
01453
US

IV. Provider business mailing address

P.O. BOX 726
LEOMINSTER MA
01453
US

V. Phone/Fax

Practice location:
  • Phone: 617-522-8110
  • Fax:
Mailing address:
  • Phone: 978-466-2692
  • Fax: 978-466-4754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number231041
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number242004.
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number242004.
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: