Provider Demographics
NPI:1891858650
Name:KHAE SAEPHANH, D.O., INC
Entity Type:Organization
Organization Name:KHAE SAEPHANH, D.O., INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KHAE
Authorized Official - Middle Name:VANG
Authorized Official - Last Name:SAEPHANH
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:408-274-3200
Mailing Address - Street 1:PO BOX 32611
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95152-2611
Mailing Address - Country:US
Mailing Address - Phone:408-274-3200
Mailing Address - Fax:408-274-8021
Practice Address - Street 1:1569 LEXANN AVE
Practice Address - Street 2:SUITE 128
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95121-1793
Practice Address - Country:US
Practice Address - Phone:408-274-3200
Practice Address - Fax:408-274-8021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9049207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20A9049OtherMEDICAL LICENCE
CA00AX90490Medicaid
CABS9580502OtherDEA NUMBER
=========OtherEIN
CAI57348Medicare UPIN