Basic Information
| Provider Information | |||||||||
| NPI: | 1629066097 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHORSAND-SAHBAIE | ||||||||
| FirstName: | MASOUD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1574 | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882021574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756279500 | ||||||||
| FaxNumber: | 5756279535 | ||||||||
| Practice Location | |||||||||
| Address1: | 407 W COUNTRY CLUB RD | ||||||||
| Address2: | |||||||||
| City: | ROSWELL | ||||||||
| State: | NM | ||||||||
| PostalCode: | 882015209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5756279110 | ||||||||
| FaxNumber: | 5756279535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2005 | ||||||||
| LastUpdateDate: | 01/26/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 96299 | NM | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | 1932187044 | 01 | NM | GROUP NPI | OTHER | 800521089 | 01 | NM | MCR GROUP ID | OTHER | 830004210 | 01 | RR MEDICARE | OTHER | P6399 | 05 | NM | MEDICAID |