Provider Demographics
NPI:1093716698
Name:KHALIL, ABBAS (MD)
Entity Type:Individual
Prefix:
First Name:ABBAS
Middle Name:
Last Name:KHALIL
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 1:825 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805-2745
Mailing Address - Country:US
Mailing Address - Phone:419-222-0808
Mailing Address - Fax:419-222-0864
Practice Address - Street 1:825 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45805-2745
Practice Address - Country:US
Practice Address - Phone:419-222-0808
Practice Address - Fax:419-222-0864
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2010-06-28
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
OH35074237K174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2080242Medicaid
OH000000140783OtherANTHEM
OHE78424Medicare UPIN