Provider Demographics
NPI:1437530862
Name:KHODAIE, ROYA
Entity type:Individual
Prefix:
First Name:ROYA
Middle Name:
Last Name:KHODAIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81557 DR CARREON BLVD # B2B3
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5517
Mailing Address - Country:US
Mailing Address - Phone:800-673-1044
Mailing Address - Fax:
Practice Address - Street 1:81557 DR CARREON BLVD # B2B3
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5517
Practice Address - Country:US
Practice Address - Phone:800-673-1044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-11
Last Update Date:2024-10-03
Deactivation Date:2024-03-01
Deactivation Code:
Reactivation Date:2024-03-13
Provider Licenses
StateLicense IDTaxonomies
CAA153964207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine