Healthcare Provider Details

I. General information

NPI: 1508022179
Provider Name (Legal Business Name): SOORENA KHOJASTEH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 10/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 E LANCASTER AVE STE 261
WYNNEWOOD PA
19096-3450
US

IV. Provider business mailing address

100 E LANCASTER AVE STE 261
WYNNEWOOD PA
19096-3450
US

V. Phone/Fax

Practice location:
  • Phone: 610-658-1928
  • Fax: 484-572-0482
Mailing address:
  • Phone: 610-658-1928
  • Fax: 484-572-0482

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD439502
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: