Healthcare Provider Details

I. General information

NPI: 1659623221
Provider Name (Legal Business Name): KATAYOUN KHOSRAVANI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2012
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7447 CENTRAL BUSINESS PARK DR SUITE 104
NORFOLK VA
23513-2831
US

IV. Provider business mailing address

PO BOX 1239
TROY MI
48099-1239
US

V. Phone/Fax

Practice location:
  • Phone: 757-853-1380
  • Fax: 855-252-4450
Mailing address:
  • Phone: 248-824-6600
  • Fax: 248-324-1477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number0101249055
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101249055
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: