Provider Demographics
NPI:1669677837
Name:KHAZAEINEZHAD, ALI (MD)
Entity Type:Individual
Prefix:DR
First Name:ALI
Middle Name:
Last Name:KHAZAEINEZHAD
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 1:3331 SPECTRUM
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3374
Mailing Address - Country:US
Mailing Address - Phone:312-953-9909
Mailing Address - Fax:
Practice Address - Street 1:742 W HIGHLAND AVE
Practice Address - Street 2:SAN MARCOS MEDICAL GROUP INC.
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-3839
Practice Address - Country:US
Practice Address - Phone:312-953-9909
Practice Address - Fax:909-881-7330
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA250973207VG0400X
CAA108351207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110093581AMedicaid
MA110093581AMedicaid