Healthcare Provider Details

I. General information

NPI: 1588720858
Provider Name (Legal Business Name): MUSTAFA A KHATIB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 W HIGHLAND AVE
SAN BERNARDINO CA
92405-3839
US

IV. Provider business mailing address

742 W HIGHLAND AVE
SAN BERNARDINO CA
92405-3839
US

V. Phone/Fax

Practice location:
  • Phone: 909-881-7320
  • Fax: 909-881-7329
Mailing address:
  • Phone: 909-881-7320
  • Fax: 909-881-7329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA92717
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: