Basic Information
| Provider Information | |||||||||
| NPI: | 1548284169 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHAKPOUR | ||||||||
| FirstName: | NAZANIN | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 12902 MAGNOLIA DRIVE | ||||||||
| Address2: | MOD A | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137453587 | ||||||||
| FaxNumber: | 8137454226 | ||||||||
| Practice Location | |||||||||
| Address1: | 12902 MAGNOLIA DRIVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888602778 | ||||||||
| FaxNumber: | 8137456511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 06/03/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ME100313 | FL | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | D63418 | GA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 0106 | 01 | MD | CAREFIRST REGIONAL | OTHER | 2134681 | 01 | MD | MDIPA | OTHER | 252001 | 01 | MD | KAISER | OTHER | 408155200 | 05 | MD | MEDICAID | 64787501 | 01 | MD | BLUE SHIELD | OTHER | 95780 | 01 | MD | GEISINGER | OTHER |