Healthcare Provider Details

I. General information

NPI: 1659356103
Provider Name (Legal Business Name): BORIS KHAMISHON., PROF. CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2005
Last Update Date: 08/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6699 ALVARADO RD 2301
SAN DIEGO CA
92120-5238
US

IV. Provider business mailing address

531 PALOMAR AVE
LA JOLLA CA
92037-6143
US

V. Phone/Fax

Practice location:
  • Phone: 619-582-2595
  • Fax: 619-229-8006
Mailing address:
  • Phone: 619-582-2595
  • Fax: 619-229-8006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. BORIS KHAMISHON
Title or Position: NEUROLOGY
Credential: MD
Phone: 619-582-2595