Provider Demographics
NPI:1700920899
Name:KAILEH, HUSAM S (MD)
Entity Type:Individual
Prefix:DR
First Name:HUSAM
Middle Name:S
Last Name:KAILEH
Suffix:
Gender:M
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 737
Mailing Address - Street 2:
Mailing Address - City:SAN JOAQUIN
Mailing Address - State:CA
Mailing Address - Zip Code:93660-0737
Mailing Address - Country:US
Mailing Address - Phone:559-693-2462
Mailing Address - Fax:559-693-4382
Practice Address - Street 1:21890 W. COLORADO AVENUE
Practice Address - Street 2:
Practice Address - City:SAN JOAQUIN
Practice Address - State:CA
Practice Address - Zip Code:93660
Practice Address - Country:US
Practice Address - Phone:559-693-2462
Practice Address - Fax:559-693-4382
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA52444207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC03875FMedicaid
CA051937Medicare ID - Type Unspecified
CAF84445Medicare UPIN