Healthcare Provider Details

I. General information

NPI: 1124083589
Provider Name (Legal Business Name): MOHSIN RIAZ KHALIQUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 10/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 SATINLEAF WAY
SAN RAMON CA
94582-5059
US

IV. Provider business mailing address

5505 SATINLEAF WAY
SAN RAMON CA
94582-5059
US

V. Phone/Fax

Practice location:
  • Phone: 925-365-1216
  • Fax:
Mailing address:
  • Phone: 925-365-1216
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number22590
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number35083976
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA 98212
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: