Healthcare Provider Details

I. General information

NPI: 1326363300
Provider Name (Legal Business Name): NIKAN H KHATIBI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2010
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1307 WEST 6TH STREET SUITE 105
CORONA CA
92882-1944
US

IV. Provider business mailing address

29911 NIGUEL #6429
LAGUNA NIGUEL CA
92677-9998
US

V. Phone/Fax

Practice location:
  • Phone: 888-873-6220
  • Fax: 888-873-6220
Mailing address:
  • Phone: 888-873-6220
  • Fax: 888-873-6220

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number20A11914
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number20A11914
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: