Provider Demographics
NPI:1275607491
Name:KHULUSI, BASIMAH (MD)
Entity Type:Individual
Prefix:
First Name:BASIMAH
Middle Name:
Last Name:KHULUSI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 W 5TH ST
Mailing Address - Street 2:SUITE 321
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3388
Mailing Address - Country:US
Mailing Address - Phone:913-208-6684
Mailing Address - Fax:
Practice Address - Street 1:255 W 5TH ST
Practice Address - Street 2:#321
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3388
Practice Address - Country:US
Practice Address - Phone:913-208-6684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA4362208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSBK317848OtherDEA
C52095Medicare UPIN
C52095Medicare UPIN