Healthcare Provider Details

I. General information

NPI: 1033266390
Provider Name (Legal Business Name): MARJORIE J KHAWAM DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 04/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3816 WOODRUFF AVE STE 302
LONG BEACH CA
90808-2146
US

IV. Provider business mailing address

3816 WOODRUFF AVE STE 302
LONG BEACH CA
90808-2146
US

V. Phone/Fax

Practice location:
  • Phone: 562-429-5300
  • Fax: 562-429-0535
Mailing address:
  • Phone: 562-429-5300
  • Fax: 562-429-0535

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE4286
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: