Healthcare Provider Details

I. General information

NPI: 1104568252
Provider Name (Legal Business Name): JUNAID KHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2022
Last Update Date: 04/10/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 TELEGRAPH AVE
OAKLAND CA
94609-3239
US

IV. Provider business mailing address

5669 MERICREST WAY
MARYSVILLE CA
95901-8386
US

V. Phone/Fax

Practice location:
  • Phone: 800-607-6377
  • Fax:
Mailing address:
  • Phone: 607-651-0025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP0504X
TaxonomyPublic Medicine Podiatrist
License Number1417962101
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: