Provider Demographics
NPI:1588720858
Name:KHATIB, MUSTAFA A (MD)
Entity type:Individual
Prefix:
First Name:MUSTAFA
Middle Name:A
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 1:742 W HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-3839
Mailing Address - Country:US
Mailing Address - Phone:909-881-7320
Mailing Address - Fax:909-881-7329
Practice Address - Street 1:742 W HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-3839
Practice Address - Country:US
Practice Address - Phone:909-881-7320
Practice Address - Fax:909-881-7329
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA92717207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92717OtherLICENSE