Healthcare Provider Details

I. General information

NPI: 1790927747
Provider Name (Legal Business Name): AL KHAN CABANEZ ALSUA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 12/15/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2185 W GRANT LINE RD TRACY MEDICAL OFFICES
TRACY CA
95377-7309
US

IV. Provider business mailing address

7373 WEST LN TPMG PHYSICIAN ADMINISTRATION
STOCKTON CA
95210-3377
US

V. Phone/Fax

Practice location:
  • Phone: 209-839-3200
  • Fax:
Mailing address:
  • Phone: 209-476-3484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA118497
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: