Healthcare Provider Details

I. General information

NPI: 1194965806
Provider Name (Legal Business Name): LYNDA MARGARET DICKERSON KHOUZAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2009
Last Update Date: 02/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1684 W SHAW AVE SUITE 101
FRESNO CA
93711-3517
US

IV. Provider business mailing address

1684 W SHAW AVE SUITE 101
FRESNO CA
93711-3517
US

V. Phone/Fax

Practice location:
  • Phone: 559-265-3098
  • Fax: 559-497-3882
Mailing address:
  • Phone: 559-265-3098
  • Fax: 559-497-3882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG88143
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: