Provider Demographics
NPI:1144593005
Name:KHALILI, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:KHALILI
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 1:185 RYKOWSKI LN STE 101
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-4055
Mailing Address - Country:US
Mailing Address - Phone:845-692-0030
Mailing Address - Fax:845-692-0037
Practice Address - Street 1:1504 BAY RD
Practice Address - Street 2:APARTMENT 704
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33139-3399
Practice Address - Country:US
Practice Address - Phone:305-401-4157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-22
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266708-12085R0202X
FLME1036842085R0202X
TN498772085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03558050Medicaid