MEDICARE: VICLINIC PC

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	207R00000X	Internal Medicine Physician
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1619461837
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VICLINIC PC

Provider Business Mailing Address
First Line	:	345 LAUREL LN
Second Line	:
City	:	HAVERFORD
State	:	PA
Zip	:	19041-1930
Country	:	US
Telephone Number	:	914-610-0950
Fax Number	:

Provider Business Practice Location Address
First Line	:	3908 KENSINGTON AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19124-4400
Country	:	US
Telephone Number	:	914-610-0950
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PHYSICIAN
Name	:	DR. SOORENA KHOJASTEH
Credential	:	MD
Telephone Number	:	914-610-0950

Provider Enumeration Date	:	06/20/2018
Last Update Date	:	06/20/2018

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Directions to “VICLINIC PC ” Practice Location

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