Provider Demographics
NPI:1073691564
Name:KHAIRA, HERKANWAL S (MD)
Entity Type:Individual
Prefix:
First Name:HERKANWAL
Middle Name:S
Last Name:KHAIRA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1860 PENNSYLVANIA AVE STE 200
Mailing Address - Street 2:200
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3550
Mailing Address - Country:US
Mailing Address - Phone:707-646-4180
Mailing Address - Fax:707-646-4181
Practice Address - Street 1:1860 PENNSYLVANIA AVE STE 200
Practice Address - Street 2:200
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3550
Practice Address - Country:US
Practice Address - Phone:707-646-4180
Practice Address - Fax:707-646-4181
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95113208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1073691564Medicaid
CA1073691564Medicaid