Healthcare Provider Details

I. General information

NPI: 1376041962
Provider Name (Legal Business Name): AMERICAN ADVANCED GASTROENTEROLOGY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 E WEBSTER ST
COLUSA CA
95932-2949
US

IV. Provider business mailing address

4120 DALE RD # J8-140
MODESTO CA
95356-9232
US

V. Phone/Fax

Practice location:
  • Phone: 209-857-4787
  • Fax: 209-248-7856
Mailing address:
  • Phone: 209-857-4787
  • Fax: 209-248-7856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA35408
License Number StateCA

VIII. Authorized Official

Name: DR. MOHAMMAD HUMAYOUN KHAN
Title or Position: PRESIDENT
Credential: MD
Phone: 312-224-8764