Healthcare Provider Details

I. General information

NPI: 1124716212
Provider Name (Legal Business Name): SINA KHAKSAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2023
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HILLMONT AVE STE 120
VENTURA CA
93003-1651
US

IV. Provider business mailing address

2499 E LAKESHORE DR., LAKE ELSINORE, CA 92530
RIVERSIDE CA
92530
US

V. Phone/Fax

Practice location:
  • Phone: 805-652-6228
  • Fax:
Mailing address:
  • Phone: 951-471-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA198615
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: