Provider Demographics
NPI:1861585903
Name:KHADEMI-KERMANSHAHI, ARDESHIR (MD)
Entity type:Individual
Prefix:
First Name:ARDESHIR
Middle Name:
Last Name:KHADEMI-KERMANSHAHI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ARDESHIR
Other - Middle Name:
Other - Last Name:KHADEMI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 5048
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33758-5048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1840 MEASE DR
Practice Address - Street 2:SUITE 407B
Practice Address - City:SAFETY HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34695-6602
Practice Address - Country:US
Practice Address - Phone:727-712-1567
Practice Address - Fax:727-796-2719
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME801142084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL272101500Medicaid
FL35700XMedicare ID - Type Unspecified
FLH25917Medicare UPIN