Provider Demographics
NPI:1801900964
Name:AZHAR, KHALID (PT)
Entity type:Individual
Prefix:
First Name:KHALID
Middle Name:
Last Name:AZHAR
Suffix:
Gender:M
Credentials:PT
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 847
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0261
Mailing Address - Country:US
Mailing Address - Phone:909-796-7700
Mailing Address - Fax:
Practice Address - Street 1:10431 COMMERCE ST
Practice Address - Street 2:SUITE A
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2833
Practice Address - Country:US
Practice Address - Phone:909-796-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT7455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT74550Medicare PIN
CAZZZ23565ZMedicare PIN