Healthcare Provider Details

I. General information

NPI: 1679736672
Provider Name (Legal Business Name): SAMIRA KHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27871 MEDICAL CENTER RD STE 120
MISSION VIEJO CA
92691-6405
US

IV. Provider business mailing address

75 ENTERPRISE STE 200
ALISO VIEJO CA
92656-2626
US

V. Phone/Fax

Practice location:
  • Phone: 714-901-2006
  • Fax: 714-901-2004
Mailing address:
  • Phone: 949-688-6205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberC172118
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number128133
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number252224
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: