Provider Demographics
NPI:1093799652
Name:KHOURDAJI, ABDALLAH (MD)
Entity Type:Individual
Prefix:DR
First Name:ABDALLAH
Middle Name:
Last Name:KHOURDAJI
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 1:801 S HAM LN
Mailing Address - Street 2:STE A
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-7501
Mailing Address - Country:US
Mailing Address - Phone:209-333-6110
Mailing Address - Fax:209-333-0724
Practice Address - Street 1:801 S HAM LN
Practice Address - Street 2:STE A
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-7501
Practice Address - Country:US
Practice Address - Phone:209-333-6110
Practice Address - Fax:209-333-0724
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-06
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A341430207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA070001716OtherRAILROAD MEDICARE
CA070001716OtherRAILROAD MEDICARE
A27391Medicare UPIN