Provider Demographics
NPI:1720019821
Name:STANISAI, KHUSHAL ALAM (MD)
Entity Type:Individual
Prefix:DR
First Name:KHUSHAL
Middle Name:ALAM
Last Name:STANISAI
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 1:10408 INDUSTRIAL CIRCLE
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-4548
Mailing Address - Country:US
Mailing Address - Phone:909-796-0363
Mailing Address - Fax:909-796-0762
Practice Address - Street 1:10408 INDUSTRIAL CIRCLE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-4548
Practice Address - Country:US
Practice Address - Phone:909-796-0363
Practice Address - Fax:909-796-0762
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30298207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A302982Medicaid
00A302982Medicare ID - Type Unspecified
CA00A302982Medicaid