NPIMap

Organization Active NPI

Fairmont Dermatology Medical Associates Inc

  • Dermatology Physician
  • Lodi, CA
National Provider Identifier
1477729291
Registry record updated Jun 13, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dermatology PhysicianTaxonomy code 207N00000X
License
00A341430 Issued in CA
Legal business name
FAIRMONT DERMATOLOGY MEDICAL ASSOCIATES INC
Practice address
801 S Ham LN Ste a
Lodi, CA 95242-7502
Phone
(209) 333-6110
Fax
(209) 333-0724
NPI assigned
May 1, 2008
Organization subpart
Yes
Parent organization
FAIRMONT DERMATLOGY MEDICAL ASSOCIATES INCAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Jun 13, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Abdallah Khourdaji, MD
Title
President
Phone
(209) 333-6110

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dermatology PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207N00000X 00A341430 CA Primary

Addresses

Primary practice location

801 S Ham LN Ste a
Lodi, CA 95242-7502

Mailing address

801 S Ham LN Ste a
Lodi, CA 95242-7502
Phone (209) 333-6110

Other identifiers 1

IdentifierTypeStateIssuer
00A341430OtherCALEGACY ID#

Other names 1

  • Abdallah Khourdaji Doing business as

National Provider Directory

National Provider Directory
Part of
Fairmont Dermatology Medical Associates Inc

Locations

801 S Ham Ln
Ste A
Lodi, CA 95242
Phone (209) 333-3376

Networks

  • BSC 65 PLUS INDIVIDUAL MAPDPlans: Blue Shield 65 Plus (HMO) (H0504-015-000, H0504); Blue Shield 65 Plus (HMO) (H0504-039-000, H0504); Blue Shield 65 Plus Plan 2 (HMO) (H0504-021-000, H0504); Blue Shield Inspire (HMO) (H0504-041-000, H0504); Blue Shield 65 Plus (HMO) (H0504-038-000, H0504); Blue Shield Inspire (HMO) (H0504-047-000, H0504); Blue Shield 65 Plus (HMO) (H0504-026-000, H0504); Blue Shield Advantage (HMO) (H0504-050-000, H0504); Blue Shield AdvantageOptimum Plan (HMO) (H5928-004-000, H5928); Blue Shield Inspire (HMO) (H0504-043-000, H0504)…

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1209600000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1213315200000",
    "number": "1477729291",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "801 S HAM LN STE A",
            "city": "LODI",
            "state": "CA",
            "postal_code": "952427502",
            "telephone_number": "209-333-6110",
            "fax_number": "209-333-0724"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "801 S HAM LN STE A",
            "city": "LODI",
            "state": "CA",
            "postal_code": "952427502",
            "telephone_number": "209-333-6110",
            "fax_number": "209-333-0724"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAIRMONT DERMATOLOGY MEDICAL ASSOCIATES INC",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "FAIRMONT DERMATLOGY MEDICAL ASSOCIATES INC",
        "enumeration_date": "2008-05-01",
        "last_updated": "2008-06-13",
        "status": "A",
        "authorized_official_last_name": "KHOURDAJI",
        "authorized_official_first_name": "ABDALLAH",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "209-333-6110",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "MD"
    },
    "taxonomies": [
        {
            "code": "207N00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dermatology",
            "state": "CA",
            "license": "00A341430",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LEGACY ID#",
            "identifier": "00A341430",
            "state": "CA"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Abdallah Khourdaji",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Lodi, CA

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 13, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.