Provider Demographics
NPI:1346538683
Name:KHAMAG, HANEEN ABDUSSALAM (MD)
Entity Type:Individual
Prefix:
First Name:HANEEN
Middle Name:ABDUSSALAM
Last Name:KHAMAG
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:PO BOX 9602
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91346-9602
Mailing Address - Country:US
Mailing Address - Phone:818-837-5559
Mailing Address - Fax:818-792-4793
Practice Address - Street 1:11165 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1113
Practice Address - Country:US
Practice Address - Phone:818-837-5785
Practice Address - Fax:818-898-1842
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA248851207R00000X
CAA127351207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A1273510Medicaid
MA248851OtherMEDICAL BOARD
CA00A1273510Medicaid