Provider Demographics
NPI:1700966652
Name:ALKHADDO, JAMIL BAWERJAN (MD)
Entity type:Individual
Prefix:
First Name:JAMIL
Middle Name:BAWERJAN
Last Name:ALKHADDO
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 1:1926 VIA CTR STE A
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-6056
Mailing Address - Country:US
Mailing Address - Phone:760-940-7000
Mailing Address - Fax:760-940-0042
Practice Address - Street 1:6185 PASEO DEL NORTE STE 100
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-1152
Practice Address - Country:US
Practice Address - Phone:760-940-7000
Practice Address - Fax:760-940-0042
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432373207R00000X, 207RE0101X
CAC186416207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102454702Medicaid
WVP00366113OtherRR MEDICARE
WV3810008116Medicaid
OHP00389706OtherRR MEDICARE
OH2722674Medicaid
OH4197657Medicare PIN
WVP00366113OtherRR MEDICARE
OHP00389706OtherRR MEDICARE
I64856Medicare UPIN
OH4197651Medicare PIN
OH4197654Medicare PIN
WV3810008116Medicaid
OH4197643Medicare PIN
PA102454702Medicaid
WV4197642Medicare PIN