Basic Information
| Provider Information | |||||||||
| NPI: | 1740921055 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHANSARI | ||||||||
| FirstName: | ROD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11500 N LOU AL DR | ||||||||
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| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770242705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7132088363 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 BLYTHE BLVD | ||||||||
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| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282035812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043552165 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2022 | ||||||||
| LastUpdateDate: | 04/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.