Provider Demographics
NPI:1548289580
Name:NAFISI, KHOSROW MEHDI (MD)
Entity type:Individual
Prefix:MR
First Name:KHOSROW
Middle Name:MEHDI
Last Name:NAFISI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1728 W GLENDALE AVE
Mailing Address - Street 2:STE 301
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021
Mailing Address - Country:US
Mailing Address - Phone:602-864-6828
Mailing Address - Fax:602-864-6859
Practice Address - Street 1:1728 W GLENDALE AVE
Practice Address - Street 2:STE 301
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021
Practice Address - Country:US
Practice Address - Phone:602-864-6828
Practice Address - Fax:602-864-6859
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ17558207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ17558Medicaid
AZAZ0325810OtherBLUE CROSS BLUE SHIELD
AZ17558Medicaid
A29213Medicare UPIN