Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207Q00000X | Family Doctor | 125.072640 | IL |
Y | 207QA0401X | Family Doctor - Addiction Medicine | 036.153612 | IL |
NPI | 1396249561 |
---|---|
Provider Name | Dr. Jasser Khairallah |
First Address | Palo Alto, CA 94304-1419 |
Second Address | Palo Alto, CA 94304-1419 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/03/2018 |
Last Update Date | 21/04/2021 |