Provider Demographics
NPI:1659345940
Name:KHAMLY, JASON YOUN-ECK (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:YOUN-ECK
Last Name:KHAMLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1314 S EUCLID ST STE 103
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-2000
Mailing Address - Country:US
Mailing Address - Phone:714-533-7357
Mailing Address - Fax:714-533-9365
Practice Address - Street 1:1314 S EUCLID ST STE 103
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92802-2000
Practice Address - Country:US
Practice Address - Phone:714-533-7357
Practice Address - Fax:714-533-9365
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA43000208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A430001Medicaid