Provider Demographics
NPI:1629066097
Name:KHORSAND-SAHBAIE, MASOUD (MD)
Entity type:Individual
Prefix:
First Name:MASOUD
Middle Name:
Last Name:KHORSAND-SAHBAIE
Suffix:
Gender:M
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:PO BOX 1574
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88202-1574
Mailing Address - Country:US
Mailing Address - Phone:575-627-9500
Mailing Address - Fax:575-627-9535
Practice Address - Street 1:407 W COUNTRY CLUB RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5209
Practice Address - Country:US
Practice Address - Phone:575-627-9110
Practice Address - Fax:575-627-9535
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM96299207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM1932187044OtherGROUP NPI
NM800521089OtherMCR GROUP ID
830004210OtherRR MEDICARE
NMP6399Medicaid
NMP6399Medicaid
NM1932187044OtherGROUP NPI
NM1238400001Medicare NSC