Provider Demographics
NPI:1396828844
Name:SROUJIEH, KHALDOUN S
Entity Type:Individual
Prefix:
First Name:KHALDOUN
Middle Name:S
Last Name:SROUJIEH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N VERMONT AVE
Mailing Address - Street 2:401
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-6005
Mailing Address - Country:US
Mailing Address - Phone:323-664-6535
Mailing Address - Fax:323-664-2964
Practice Address - Street 1:1300 N VERMONT AVE
Practice Address - Street 2:401
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6005
Practice Address - Country:US
Practice Address - Phone:323-664-6535
Practice Address - Fax:323-664-2964
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2022-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33508207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA33508AOtherMEDICARE PPIN
CA00A335080Medicaid
CA00A335080Medicaid
CAHW7714Medicare PIN
CAD71917Medicare UPIN