Healthcare Provider Details

I. General information

NPI: 1730380718
Provider Name (Legal Business Name): MEHRI KHATIBI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 11/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W COOLIDGE AVE
MODESTO CA
95350-4447
US

IV. Provider business mailing address

200 W COOLIDGE AVE
MODESTO CA
95350-4447
US

V. Phone/Fax

Practice location:
  • Phone: 209-577-5005
  • Fax: 209-521-1533
Mailing address:
  • Phone: 209-577-5005
  • Fax: 209-521-1533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberA 113691
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: