Basic Information
| Provider Information | |||||||||
| NPI: | 1437278603 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHODDAMI | ||||||||
| FirstName: | SEYED | ||||||||
| MiddleName: | MOHAMMAD REZA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5855 OLIVAS PARK DR | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930037672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056672801 | ||||||||
| FaxNumber: | 8056672865 | ||||||||
| Practice Location | |||||||||
| Address1: | 2705 LOMA VISTA RD | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930031581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056434067 | ||||||||
| FaxNumber: | 8056434587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 06/01/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2088P0231X | A109665 | CA | N | Allopathic & Osteopathic Physicians | Urology | Pediatric Urology | 208800000X | A109665 | CA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | A109665 | 01 | CA | CALIFORNIA STATE | OTHER |