Provider Demographics
NPI:1417051749
Name:KHALIL KELADA, HAYNE Y (MD)
Entity Type:Individual
Prefix:
First Name:HAYNE
Middle Name:Y
Last Name:KHALIL KELADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:HAYNE
Other - Middle Name:Y
Other - Last Name:KHALIL-KELADA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1000 CAMERADO DR
Mailing Address - Street 2:
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-8864
Mailing Address - Country:US
Mailing Address - Phone:530-677-3688
Mailing Address - Fax:530-677-5563
Practice Address - Street 1:1000 CAMERADO DR
Practice Address - Street 2:
Practice Address - City:CAMERON PARK
Practice Address - State:CA
Practice Address - Zip Code:95682-8864
Practice Address - Country:US
Practice Address - Phone:530-677-3688
Practice Address - Fax:530-677-5563
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A383740207Q00000X
CAA038374207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A383740OtherANTHEM
080022454OtherRAILROAD H CARE
CA00A383740Medicaid
C03979Medicare UPIN