Healthcare Provider Details

I. General information

NPI: 1144547829
Provider Name (Legal Business Name): AMIR HOSSAIN KHODABANDELOU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2010
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 SAINT ANDREWS CROSSOVER
SEVERNA PARK MD
21146-2403
US

IV. Provider business mailing address

6 SAINT ANDREWS CROSSOVER
SEVERNA PARK MD
21146-2403
US

V. Phone/Fax

Practice location:
  • Phone: 443-524-2737
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License NumberC0003440
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC03440
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: