Provider Demographics
NPI:1013177633
Name:KHAJA, NIDAL (DPM)
Entity Type:Individual
Prefix:DR
First Name:NIDAL
Middle Name:
Last Name:KHAJA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:955 DEEP VALLEY DR
Mailing Address - Street 2:# 4055
Mailing Address - City:PALOS VERDES PENINSULA
Mailing Address - State:CA
Mailing Address - Zip Code:90274-3876
Mailing Address - Country:US
Mailing Address - Phone:310-538-1110
Mailing Address - Fax:310-538-0929
Practice Address - Street 1:1246 W 155TH ST
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-4011
Practice Address - Country:US
Practice Address - Phone:310-768-2256
Practice Address - Fax:310-323-0914
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAEL1636213ES0103X
CAE4807213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery