MEDICARE: BORIS KHAMISHON., PROF. CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician

General Provider Information

NPI Number	:	1659356103
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BORIS KHAMISHON., PROF. CORP

Provider Business Mailing Address
First Line	:	531 PALOMAR AVE
Second Line	:
City	:	LA JOLLA
State	:	CA
Zip	:	92037-6143
Country	:	US
Telephone Number	:	619-582-2595
Fax Number	:	619-229-8006

Provider Business Practice Location Address
First Line	:	6699 ALVARADO RD
Second Line	:	2301
City	:	SAN DIEGO
State	:	CA
Zip	:	92120-5238
Country	:	US
Telephone Number	:	619-582-2595
Fax Number	:	619-229-8006

Authorized Official
Title or Position	:	NEUROLOGY
Name	:	MR. BORIS KHAMISHON
Credential	:	MD
Telephone Number	:	619-582-2595

Provider Enumeration Date	:	12/07/2005
Last Update Date	:	08/04/2016

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