Provider Demographics
NPI:1891431334
Name:AL SMADI, KHALED IBRAHIM MOH'D
Entity Type:Individual
Prefix:
First Name:KHALED
Middle Name:IBRAHIM MOH'D
Last Name:AL SMADI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6155 PALM AVE APARTMENT 1409
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92407
Mailing Address - Country:US
Mailing Address - Phone:951-419-9070
Mailing Address - Fax:
Practice Address - Street 1:2101 N. WATERMAN AVENUE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404
Practice Address - Country:US
Practice Address - Phone:909-644-5892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2023-01-25
Deactivation Date:2022-12-19
Deactivation Code:
Reactivation Date:2023-01-24
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program