Healthcare Provider Details

I. General information

NPI: 1487061834
Provider Name (Legal Business Name): ABDULLAH KHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2014
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST RM A890A
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

11234 ANDERSON ST RM A890A
LOMA LINDA CA
92354-2804
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-7698
  • Fax:
Mailing address:
  • Phone: 909-558-7698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA148163
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberA148163
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: