Provider Demographics
NPI:1033266390
Name:KHAWAM, MARJORIE J (DPM)
Entity Type:Individual
Prefix:DR
First Name:MARJORIE
Middle Name:J
Last Name:KHAWAM
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3816 WOODRUFF AVE
Mailing Address - Street 2:STE 302
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90808-2146
Mailing Address - Country:US
Mailing Address - Phone:562-429-5300
Mailing Address - Fax:562-429-0535
Practice Address - Street 1:3816 WOODRUFF AVE
Practice Address - Street 2:STE 302
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90808-2146
Practice Address - Country:US
Practice Address - Phone:562-429-5300
Practice Address - Fax:562-429-0535
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4286213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E42860Medicaid
CA480034704OtherRAILROAD MEDICARE
CA000E42860Medicaid
U81170Medicare UPIN
CA5408760002Medicare NSC