Provider Demographics
NPI:1508296146
Name:KHEMARA FAMILY MEDICAL CLINIC INC.
Entity Type:Organization
Organization Name:KHEMARA FAMILY MEDICAL CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NAGASAMUDRA
Authorized Official - Middle Name:S
Authorized Official - Last Name:ASHOK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:562-439-3803
Mailing Address - Street 1:440 REDONDO AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90814-5145
Mailing Address - Country:US
Mailing Address - Phone:562-439-3803
Mailing Address - Fax:866-593-7781
Practice Address - Street 1:440 REDONDO AVE STE 201
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90814-5145
Practice Address - Country:US
Practice Address - Phone:562-439-3803
Practice Address - Fax:866-593-7781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-18
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41589208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA41589OtherMEDICAL LICENSE
CA10940873OtherCAQA PROVIDER ENROLLMENT
CAZZZ58486YOtherBLUE SHIELD PROVIDER #