Provider Demographics
NPI:1649376971
Name:KHALED, EBTESAM (MD)
Entity type:Individual
Prefix:DR
First Name:EBTESAM
Middle Name:
Last Name:KHALED
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 131
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-0131
Mailing Address - Country:US
Mailing Address - Phone:714-375-2077
Mailing Address - Fax:714-375-2082
Practice Address - Street 1:17772 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-6819
Practice Address - Country:US
Practice Address - Phone:909-305-0714
Practice Address - Fax:909-394-7415
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA495382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A495382Medicaid
CAA49538Medicare ID - Type Unspecified
CA00A495382Medicaid