Provider Demographics
NPI:1164720363
Name:MAHMOUD KHATTAB MD INC
Entity Type:Organization
Organization Name:MAHMOUD KHATTAB MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAHMOUD
Authorized Official - Middle Name:
Authorized Official - Last Name:KHATTAB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-691-6666
Mailing Address - Street 1:9390 BIG HORN BLVD
Mailing Address - Street 2:SUITE 145
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-7978
Mailing Address - Country:US
Mailing Address - Phone:916-691-6666
Mailing Address - Fax:916-691-6668
Practice Address - Street 1:9390 BIG HORN BLVD
Practice Address - Street 2:SUITE 145
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7978
Practice Address - Country:US
Practice Address - Phone:916-691-6666
Practice Address - Fax:916-691-6668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-11
Last Update Date:2011-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97693207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty