Provider Demographics
NPI:1134189590
Name:KHALSA, PRABHJOT SINGH (MD)
Entity type:Individual
Prefix:DR
First Name:PRABHJOT
Middle Name:SINGH
Last Name:KHALSA
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 1:722 MOWRY AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-4115
Mailing Address - Country:US
Mailing Address - Phone:510-713-3390
Mailing Address - Fax:510-713-3393
Practice Address - Street 1:722 MOWRY AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-4115
Practice Address - Country:US
Practice Address - Phone:510-713-3390
Practice Address - Fax:510-713-3393
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-27
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG662632084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G662631Medicaid
CA00G662631Medicaid
00G662630Medicare PIN