Healthcare Provider Details

I. General information

NPI: 1093799652
Provider Name (Legal Business Name): ABDALLAH KHOURDAJI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 S HAM LN STE A
LODI CA
95242-7501
US

IV. Provider business mailing address

801 S HAM LN STE A
LODI CA
95242-7501
US

V. Phone/Fax

Practice location:
  • Phone: 209-333-6110
  • Fax: 209-333-0724
Mailing address:
  • Phone: 209-333-6110
  • Fax: 209-333-0724

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number00A341430
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: