Provider Demographics
NPI:1144547829
Name:KHODABANDELOU, AMIR HOSSAIN
Entity type:Individual
Prefix:
First Name:AMIR
Middle Name:HOSSAIN
Last Name:KHODABANDELOU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 SAINT ANDREWS CROSSOVER
Mailing Address - Street 2:
Mailing Address - City:SEVERNA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:21146-2403
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6 SAINT ANDREWS CROSSOVER
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-2403
Practice Address - Country:US
Practice Address - Phone:443-524-2737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-21
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003440261QX0100X
MDC03440363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine