Provider Demographics
NPI:1497277123
Name:KHOLMATOV, ROOSTAM M (MD)
Entity type:Individual
Prefix:
First Name:ROOSTAM
Middle Name:M
Last Name:KHOLMATOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RUSTAM
Other - Middle Name:MUSURMANKULOVICH
Other - Last Name:HOLMATOV
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5150 MAE ANNE AVE STE 405-1082
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89523-1858
Mailing Address - Country:US
Mailing Address - Phone:775-256-9494
Mailing Address - Fax:775-243-2240
Practice Address - Street 1:5150 MAE ANNE AVE STE 405-1082
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89523-1858
Practice Address - Country:US
Practice Address - Phone:775-256-9494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-14
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC92309207R00000X
VA0101282111207R00000X
AK223343207R00000X
PAMD485581207R00000X
RIMD19899207R00000X
NY330091207R00000X
ORMD220014207R00000X
MA1020093207R00000X
HIMD-24410207R00000X
FLME168657207R00000X
NMMD2024-0481207R00000X
ARE-18151207R00000X
MO2024024345207R00000X
NV20073208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist