Provider Demographics
NPI:1316979917
Name:KHAZAENI, LEILA (MD)
Entity type:Individual
Prefix:
First Name:LEILA
Middle Name:
Last Name:KHAZAENI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11370 ANDERSON ST STE 1800
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3450
Mailing Address - Country:US
Mailing Address - Phone:909-558-2154
Mailing Address - Fax:909-558-2180
Practice Address - Street 1:11370 ANDERSON ST
Practice Address - Street 2:SUITE 1800
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3450
Practice Address - Country:US
Practice Address - Phone:909-558-2180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92331207W00000X, 207WX0110X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0110XAllopathic & Osteopathic PhysiciansOphthalmologyPediatric Ophthalmology and Strabismus Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I39705Medicare UPIN
00A923310Medicare ID - Type Unspecified