Provider Demographics
NPI:1821271420
Name:MORRIS KOKHAB, M.D., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MORRIS KOKHAB, M.D., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:PROF
Authorized Official - First Name:MORRIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KOKHAB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-932-1122
Mailing Address - Street 1:974 W FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3728
Mailing Address - Country:US
Mailing Address - Phone:909-932-1122
Mailing Address - Fax:909-932-9292
Practice Address - Street 1:974 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3728
Practice Address - Country:US
Practice Address - Phone:909-932-1122
Practice Address - Fax:909-932-9292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75850261QM2500X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA75850CMedicare PIN
CAWA75850BMedicare PIN
CAH68887Medicare UPIN