Khashayar Ebrahimzadeh, MD
Individual provider Active NPI Pediatrics Physician · Blythe, CA
NPI 1770144016 · NPPES record last updated Feb 7, 2025
Key facts
- NPI
- 1770144016
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Pediatrics Physician 208000000X
- License
- A176374 (CA)
- Practice address
- 1415 W Hobsonway
Blythe, CA 92225-1479 - Phone
- (760) 922-4981
- NPI assigned
- Jun 26, 2019
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 4
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in CA
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: Yes
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20220927002146 | CA | Practitioner - Pediatric Medicine | 8921484031 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| A176374 | CA | MD | Pediatrics Physician |
| 4351045098 | MI | MD | Pediatrics Physician |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Clinicas de Salud del Pueblo, Inc | Current | Accepting new patients | |
| Clinicas de Salud del Pueblo, Inc | Current |
Accepting new patients | |
| Clinicas de Salud del Pueblo Inc. | Current |
Accepting new patients | |
| Clinicas de Salud del Pueblo, Inc. | Past | Accepting new patients |
Locations
321 W Hobsonway
Ste C
Blythe, CA 92225
Phone (760) 922-4981
852 E Danenberg Dr
El Centro, CA 92243
Phone (760) 352-2257
Interoperability endpoints
- khashayar.ebrahimzadeh.p1@direct.cdsdp.nextgenshare.com
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Pediatrics Physician | 208000000X | 4351045098 | MI | |
| Pediatrics Physician | 208000000X | A176374 | CA | Yes |
Addresses
Primary practice location
1415 W Hobsonway
Blythe, CA 92225-1479
Mailing address
1415 W Hobsonway
Blythe, CA 92225-1479
Phone (760) 922-4981
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 4351045098 | Medicaid | MI |
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| CONNECT URL | Pediatrics |
Other providers in Blythe, CA
- Dharia DDS Professional Dental Corporation
- David DO
- Gregory C. Doane
- Frank Wayne Dudley Jr.
- David (None) Dunn
- Christopher Edmonds
- Rochella Edwards
- Epifania V Nicolas
- Epifania V Nicolas DDS Inc
- Epifania V Nicolas DDS Inc.
All providers in Blythe, CA · Pediatrics Physician in California
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Feb 7, 2025. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.