Provider Demographics
NPI:1144274721
Name:FATTAHI, KHALIL (MD)
Entity type:Individual
Prefix:DR
First Name:KHALIL
Middle Name:
Last Name:FATTAHI
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 1:2951 WINCHESTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-5319
Mailing Address - Country:US
Mailing Address - Phone:408-378-3467
Mailing Address - Fax:
Practice Address - Street 1:2951 WINCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-5319
Practice Address - Country:US
Practice Address - Phone:408-378-3467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0A43193174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A431930Medicare ID - Type UnspecifiedPHYSICIAN