Basic Information
| Provider Information | |||||||||
| NPI: | 1528062874 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAFAJA | ||||||||
| FirstName: | ISSAM | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 FLOWER ST | ||||||||
| Address2: | STE A | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912013000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186372000 | ||||||||
| FaxNumber: | 8188887018 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 FLOWER ST | ||||||||
| Address2: | STE A | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912013000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185526230 | ||||||||
| FaxNumber: | 8188887018 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2005 | ||||||||
| LastUpdateDate: | 11/05/2013 | ||||||||
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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 | 207R00000X | A54280 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A542800 | 05 | CA | MEDICAID |