Healthcare Provider Details

I. General information

NPI: 1881696060
Provider Name (Legal Business Name): SAMEH N KHOUZAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4160 LITTLE YORK RD STE 20
DAYTON OH
45414
US

IV. Provider business mailing address

4160 LITTLE YORK RD STE 20
DAYTON OH
45414-5803
US

V. Phone/Fax

Practice location:
  • Phone: 937-454-9527
  • Fax: 937-454-9532
Mailing address:
  • Phone: 937-454-9527
  • Fax: 937-454-9532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number084219
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number084219
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: