Healthcare Provider Details

I. General information

NPI: 1174688071
Provider Name (Legal Business Name): KHALED M SELIM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 11/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25865 BARTON RD STE 101
LOMA LINDA CA
92354
US

IV. Provider business mailing address

FILE NUMBER 54701
LOS ANGELES CA
90074-4701
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-3636
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number29162
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207RT0003X
TaxonomyTransplant Hepatology Physician
License NumberA55853
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RT0003X
TaxonomyTransplant Hepatology Physician
License Number29162
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA55853
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: