Healthcare Provider Details

I. General information

NPI: 1043330103
Provider Name (Legal Business Name): HOOSHANG KHOSHNEVIS-YAZDI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36000 DARNALL LOOP DEPARTMENT OF RADIOLOGY
FORT HOOD TX
76544-5095
US

IV. Provider business mailing address

1410 LINDA LN
COPPERAS COVE TX
76522-1239
US

V. Phone/Fax

Practice location:
  • Phone: 254-286-7790
  • Fax: 254-286-7795
Mailing address:
  • Phone: 254-547-1702
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number44509
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: