Provider Demographics
NPI:1386901593
Name:KHATIB, SHADI AL (MD)
Entity type:Individual
Prefix:
First Name:SHADI
Middle Name:AL
Last Name:KHATIB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 FLYNN RD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5092
Mailing Address - Country:US
Mailing Address - Phone:805-673-3930
Mailing Address - Fax:805-659-3217
Practice Address - Street 1:450 W CLARA ST
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93033-8363
Practice Address - Country:US
Practice Address - Phone:805-488-0210
Practice Address - Fax:805-488-0510
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA117754208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics