Provider Demographics
NPI:1427121037
Name:KHADEMI, ALI (DO)
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:KHADEMI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4145 CLARES ST
Mailing Address - Street 2:STE A
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010-2053
Mailing Address - Country:US
Mailing Address - Phone:831-662-9999
Mailing Address - Fax:831-662-9998
Practice Address - Street 1:4145 CLARES ST STE A
Practice Address - Street 2:
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010-2053
Practice Address - Country:US
Practice Address - Phone:831-662-9999
Practice Address - Fax:831-662-9998
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2020-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A 7421207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH47780Medicare UPIN