Provider Demographics
NPI:1548284169
Name:KHAKPOUR, NAZANIN I (MD)
Entity type:Individual
Prefix:
First Name:NAZANIN
Middle Name:I
Last Name:KHAKPOUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12902 MAGNOLIA DRIVE
Mailing Address - Street 2:MOD A
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612
Mailing Address - Country:US
Mailing Address - Phone:813-745-3587
Mailing Address - Fax:813-745-4226
Practice Address - Street 1:12902 MAGNOLIA DRIVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612
Practice Address - Country:US
Practice Address - Phone:888-860-2778
Practice Address - Fax:813-745-6511
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME100313208600000X
GAD63418208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD0106OtherCAREFIRST REGIONAL
MD2134681OtherMDIPA
MD252001OtherKAISER
MD408155200Medicaid
MD64787501OtherBLUE SHIELD
MD95780OtherGEISINGER
MD408155200Medicaid
MDI19977Medicare UPIN
MD95780OtherGEISINGER