Provider Demographics
NPI:1467200154
Name:KHAWAM, ANDRE ELIAS (DO)
Entity type:Individual
Prefix:
First Name:ANDRE
Middle Name:ELIAS
Last Name:KHAWAM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:638 S PATHFINDER TRL
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92807-4778
Mailing Address - Country:US
Mailing Address - Phone:714-331-4866
Mailing Address - Fax:
Practice Address - Street 1:1770 N ORANGE GROVE AVE STE 201
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-3027
Practice Address - Country:US
Practice Address - Phone:909-469-9490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program