Provider Demographics
NPI:1972641124
Name:KHUSHAL A STANISAI, MD INC
Entity Type:Organization
Organization Name:KHUSHAL A STANISAI, MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:LAMOUREUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-796-7803
Mailing Address - Street 1:10408 INDUSTRIAL CIR
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 CIR
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA30298207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A302982Medicaid
110089935OtherRAILROAD MEDICARE
00A30298Medicare PIN