Healthcare Provider Details

I. General information

NPI: 1053621060
Provider Name (Legal Business Name): MASOUD KHORSAND-SAHBAIE, MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2010
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3028 N. GRIMES
HOBBS NM
88241
US

IV. Provider business mailing address

PO BOX 1574
ROSWELL NM
88202-1574
US

V. Phone/Fax

Practice location:
  • Phone: 575-392-0222
  • Fax: 575-392-0200
Mailing address:
  • Phone: 575-627-9505
  • Fax: 877-749-7764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number96299
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberMD2012-0091
License Number StateNM

VIII. Authorized Official

Name: BRENDA COTTRELL
Title or Position: BUSINESS SYSTEMS/CREDENTIALING MGR
Credential:
Phone: 575-627-9508