Provider Demographics
NPI:1710009808
Name:KHAMISEH, GHASSAN (MD)
Entity Type:Individual
Prefix:
First Name:GHASSAN
Middle Name:
Last Name:KHAMISEH
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 1:2800 PACIFIC AVE STE D
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-1468
Mailing Address - Country:US
Mailing Address - Phone:562-337-8401
Mailing Address - Fax:562-337-8404
Practice Address - Street 1:2800 PACIFIC AVE STE D
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1468
Practice Address - Country:US
Practice Address - Phone:562-337-8401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60718207R00000X
CAA060718207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG10792Medicare UPIN