Provider Demographics
NPI:1710202684
Name:KHADER, ADAM (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:ADAM
Middle Name:
Last Name:KHADER
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2312
Mailing Address - Country:US
Mailing Address - Phone:310-449-5258
Mailing Address - Fax:310-315-4017
Practice Address - Street 1:2200 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2312
Practice Address - Country:US
Practice Address - Phone:310-449-5258
Practice Address - Fax:310-315-4017
Is Sole Proprietor?:No
Enumeration Date:2010-04-02
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA154883208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program