Healthcare Provider Details

I. General information

NPI: 1669677837
Provider Name (Legal Business Name): ALI KHAZAEI NEZHAD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 10/03/2024
Certification Date: 10/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 W HIGHLAND AVE SAN MARCOS MEDICAL GROUP INC.
SAN BERNARDINO CA
92405-3839
US

IV. Provider business mailing address

27652 HOMESTEAD RD
LAGUNA NIGUEL CA
92677-6603
US

V. Phone/Fax

Practice location:
  • Phone: 312-953-9909
  • Fax: 909-881-7330
Mailing address:
  • Phone: 312-953-9909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number250973
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA108351
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: