Healthcare Provider Details

I. General information

NPI: 1134189590
Provider Name (Legal Business Name): PRABHJOT SINGH KHALSA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 09/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

722 MOWRY AVE
FREMONT CA
94536-4115
US

IV. Provider business mailing address

722 MOWRY AVE
FREMONT CA
94536-4115
US

V. Phone/Fax

Practice location:
  • Phone: 510-713-3390
  • Fax: 510-713-3393
Mailing address:
  • Phone: 510-713-3390
  • Fax: 510-713-3393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberG66263
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberG66263
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: