Healthcare Provider Details

I. General information

NPI: 1386901593
Provider Name (Legal Business Name): SHADI AL KHATIB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2012
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 W CLARA ST
OXNARD CA
93033-8363
US

IV. Provider business mailing address

1040 FLYNN RD
CAMARILLO CA
93012-5092
US

V. Phone/Fax

Practice location:
  • Phone: 805-488-0210
  • Fax: 805-488-0510
Mailing address:
  • Phone: 805-673-3930
  • Fax: 805-659-3217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number117754
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: