Healthcare Provider Details

I. General information

NPI: 1821708850
Provider Name (Legal Business Name): WASEEM KHADER DO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2022
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11878 AVENUE OF INDUSTRY
SAN DIEGO CA
92128-3423
US

IV. Provider business mailing address

PO BOX 1770
LA MESA CA
91944-1770
US

V. Phone/Fax

Practice location:
  • Phone: 442-286-7907
  • Fax:
Mailing address:
  • Phone: 619-464-1165
  • Fax: 619-567-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: WASEEM KHADER
Title or Position: OWNER
Credential: DO
Phone: 442-286-7907