Healthcare Provider Details

I. General information

NPI: 1679570527
Provider Name (Legal Business Name): SHAMSUDDIN KHWAJA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E HERNDON AVE VALLEY CARDIAC SURGERY, SUITE 107
FRESNO CA
93720-3238
US

IV. Provider business mailing address

1400 AMBASSADOR ST APT. 111
LOS ANGELES CA
90035-2858
US

V. Phone/Fax

Practice location:
  • Phone: 559-435-3740
  • Fax: 559-261-9073
Mailing address:
  • Phone: 310-551-2772
  • Fax: 310-551-2891

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberA85907
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberL3718
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: