1811317100 NPI number — MR. KHALIL MATEEN-FARUQ

Table of content: (NPI 1205486578)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811317100 NPI number — MR. KHALIL MATEEN-FARUQ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATEEN-FARUQ
Provider First Name:
KHALIL
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811317100
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/24/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1400 N JOHNSON AVE STE 101
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EL CAJON
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92020-1651
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-442-0277
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4001 EL CAJON BLVD STE 206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92105-1111
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-280-2300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/24/2014

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)