Healthcare Provider Details

I. General information

NPI: 1992749683
Provider Name (Legal Business Name): ROUZBEH K KORDESTANI MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 07/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 SONCY ST 137
AMARILLO TX
79119
US

IV. Provider business mailing address

PO BOX 32901
AMARILLO TX
79120-2901
US

V. Phone/Fax

Practice location:
  • Phone: 806-322-5438
  • Fax:
Mailing address:
  • Phone: 806-322-5438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ROUZBEH KHOSROVI KORDESTANI
Title or Position: OWNER
Credential: MD PA
Phone: 806-322-5438