Provider Demographics
NPI:1720008212
Name:KHASIMUDDIN, SYED A (MD)
Entity Type:Individual
Prefix:DR
First Name:SYED
Middle Name:A
Last Name:KHASIMUDDIN
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 1:632 W GIBSON RD
Mailing Address - Street 2:
Mailing Address - City:WOODLAND
Mailing Address - State:CA
Mailing Address - Zip Code:95695-5169
Mailing Address - Country:US
Mailing Address - Phone:530-662-3961
Mailing Address - Fax:
Practice Address - Street 1:632 W GIBSON RD
Practice Address - Street 2:
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-5169
Practice Address - Country:US
Practice Address - Phone:530-662-3961
Practice Address - Fax:530-756-5817
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87340207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A873400OtherBLUE SHIELD
CA00A873400Medicaid
CAP00284490OtherRR MEDICARE
CA00A873400Medicaid
CA00G769031Medicare PIN
CA00A873400OtherBLUE SHIELD