Basic Information
| Provider Information | |||||||||
| NPI: | 1457320905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHOUZAM | ||||||||
| FirstName: | HANI | ||||||||
| MiddleName: | RAOUL | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2625 E DIVISADERO ST | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937211431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594432682 | ||||||||
| FaxNumber: | 5594432681 | ||||||||
| Practice Location | |||||||||
| Address1: | 4441 E KINGS CANYON RD | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937023604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5596009171 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2006 | ||||||||
| LastUpdateDate: | 03/08/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084A0401X | C50701 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Addiction Medicine | 2084P0805X | C50701 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry | 2084P0800X | C50701 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.