Provider Demographics
NPI:1245594167
Name:KHOURDAJI, AYAD (MD)
Entity Type:Individual
Prefix:
First Name:AYAD
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 1:830 S HAM LN STE 26
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-7510
Mailing Address - Country:US
Mailing Address - Phone:209-368-6661
Mailing Address - Fax:
Practice Address - Street 1:830 S HAM LN STE 26
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-7510
Practice Address - Country:US
Practice Address - Phone:209-368-6661
Practice Address - Fax:209-333-7655
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-25
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA153658208800000X
MI4301101419208800000X
VA0101261869208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology