Provider Demographics
NPI:1790172179
Name:KHAZANEHDARI, SHAHAB (MD)
Entity type:Individual
Prefix:DR
First Name:SHAHAB
Middle Name:
Last Name:KHAZANEHDARI
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 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:101 THE CITY DR S
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3201
Practice Address - Country:US
Practice Address - Phone:714-456-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-23
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3348072084N0400X, 2084A2900X
CAA1707192084A2900X
FLME1501392084A2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A2900XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurocritical Care
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology