Provider Demographics
NPI:1477729291
Name:FAIRMONT DERMATOLOGY MEDICAL ASSOCIATES INC
Entity Type:Organization
Organization Name:FAIRMONT DERMATOLOGY MEDICAL ASSOCIATES INC
Other - Org Name:ABDALLAH KHOURDAJI
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ABDALLAH
Authorized Official - Middle Name:
Authorized Official - Last Name:KHOURDAJI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-333-6110
Mailing Address - Street 1:801 S HAM LN STE A
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-7502
Mailing Address - Country:US
Mailing Address - Phone:209-333-6110
Mailing Address - Fax:209-333-0724
Practice Address - Street 1:801 S HAM LN STE A
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-7502
Practice Address - Country:US
Practice Address - Phone:209-333-6110
Practice Address - Fax:209-333-0724
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FAIRMONT DERMATLOGY MEDICAL ASSOCIATES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-01
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A341430207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A341430OtherLEGACY ID#
CAA27391Medicare UPIN