Healthcare Provider Details

I. General information

NPI: 1194896043
Provider Name (Legal Business Name): AHMED KHEITER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 10/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3865 JACKSON ST
RIVERSIDE CA
92503-3919
US

IV. Provider business mailing address

PO BOX 78222
CORONA CA
92877-0140
US

V. Phone/Fax

Practice location:
  • Phone: 951-688-2211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA89639
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: