MEDICARE: DR. KHOSROW MAHDAVI MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RH0000X	Hematology (Internal Medicine) Physician	A33589	CA
2	174400000X	Specialist	A33589	CA
3	207RX0202X	Medical Oncology Physician	A33589	CA
4	207RH0003X	Hematology & Oncology Physician	A33589	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A33589	OTHER	CA	LICENSE NUMBER

General Provider Information

NPI Number	:	1275536773
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KHOSROW MAHDAVI MD

Provider Business Mailing Address
First Line	:	200 S MANCHESTER AVE STE 300
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92868-3219
Country	:	US
Telephone Number	:	714-456-2986
Fax Number	:

Provider Business Practice Location Address
First Line	:	1640 NEWPORT BLVD STE 400
Second Line	:
City	:	COSTA MESA
State	:	CA
Zip	:	92627-3786
Country	:	US
Telephone Number	:	949-999-2400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2005
Last Update Date	:	11/15/2023

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Directions to “ DR. KHOSROW MAHDAVI MD” Practice Location

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