Healthcare Provider Details

I. General information

NPI: 1205928348
Provider Name (Legal Business Name): IRINA KHIDEKEL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: N/A N/A N/A N/A

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3635 CALIFORNIA ST
SAN FRANCISCO CA
94118-1701
US

IV. Provider business mailing address

3635 CALIFORNIA ST
SAN FRANCISCO CA
94118-1701
US

V. Phone/Fax

Practice location:
  • Phone: 415-752-0277
  • Fax: 415-752-5333
Mailing address:
  • Phone: 415-752-0277
  • Fax: 415-752-5333

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA51703
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: