Provider Demographics
NPI:1023058963
Name:KHOUZAM, ATEF (MD)
Entity type:Individual
Prefix:
First Name:ATEF
Middle Name:
Last Name:KHOUZAM
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:PO BOX 3579
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92659-8579
Mailing Address - Country:US
Mailing Address - Phone:949-574-0777
Mailing Address - Fax:949-650-3505
Practice Address - Street 1:361 HOSPITAL RD
Practice Address - Street 2:322
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3522
Practice Address - Country:US
Practice Address - Phone:949-574-0777
Practice Address - Fax:949-650-3505
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40228207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA110125134OtherMEDICARE RAILROAD
CAWA40228AMedicare PIN
CA110125134OtherMEDICARE RAILROAD