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General NPI Number Information
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NPI Number | 1477729291
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Entity Type | Organization
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Legal Business Name | FAIRMONT DERMATOLOGY MEDICAL ASSOCIATES INC
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Dates
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Enumeration Date | 05/01/2008
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Last Update Date | 06/13/2008
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Provider Practice Location Address
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Address Line | 801 S HAM LN STE A
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City | LODI
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State | CA
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Zip | 95242-7502
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Country | US
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Telephone | 209-333-6110
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Fax | 209-333-0724
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Provider Business Mailing Address
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Address Line | 801 S HAM LN STE A
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City | LODI
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State | CA
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Zip | 95242-7502
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Country | US
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Telephone | 209-333-6110
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Fax | 209-333-0724
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ABDALLAH KHOURDAJI
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Credential | MD
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Telephone | 209-333-6110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 00A341430
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License Number State | CA
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