Healthcare Provider Details

I. General information

NPI: 1205287208
Provider Name (Legal Business Name): KHALIDA PATHAN MD DBA KP MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2016
Last Update Date: 04/30/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 MORADA PL
ALTADENA CA
91001-2425
US

IV. Provider business mailing address

888 MORADA PL
ALTADENA CA
91001-2425
US

V. Phone/Fax

Practice location:
  • Phone: 626-696-3692
  • Fax:
Mailing address:
  • Phone: 626-696-3692
  • Fax: 626-696-3784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberA97589
License Number StateCA

VIII. Authorized Official

Name: DR. KHALIDA A PATHAN
Title or Position: PHYSICIAN/SOLE PROPRIETOR
Credential: MD
Phone: 626-696-3692