Basic Information
| Provider Information | |||||||||
| NPI: | 1386901593 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHATIB | ||||||||
| FirstName: | SHADI | ||||||||
| MiddleName: | AL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1040 FLYNN RD | ||||||||
| Address2: | |||||||||
| City: | CAMARILLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930125092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056733930 | ||||||||
| FaxNumber: | 8056593217 | ||||||||
| Practice Location | |||||||||
| Address1: | 450 W CLARA ST | ||||||||
| Address2: | |||||||||
| City: | OXNARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930338363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054880210 | ||||||||
| FaxNumber: | 8054880510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2012 | ||||||||
| LastUpdateDate: | 02/22/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 117754 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.