Healthcare Provider Details

I. General information

NPI: 1528621901
Provider Name (Legal Business Name): NICOLE KHEZRI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2019
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1798 N GAREY AVE
POMONA CA
91767-2918
US

IV. Provider business mailing address

10540 WILSHIRE BLVD
LOS ANGELES CA
90024-4502
US

V. Phone/Fax

Practice location:
  • Phone: 909-865-9500
  • Fax:
Mailing address:
  • Phone: 516-658-7745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License NumberA188564
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: