Provider Demographics
NPI:1164469409
Name:RASSOUL, KHALID (MD)
Entity Type:Individual
Prefix:
First Name:KHALID
Middle Name:
Last Name:RASSOUL
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 1:601 S HARBOUR ISLAND BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33602-5925
Mailing Address - Country:US
Mailing Address - Phone:800-480-5243
Mailing Address - Fax:800-928-7449
Practice Address - Street 1:2900 KIRBY RD STE 11
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-8207
Practice Address - Country:US
Practice Address - Phone:901-440-3190
Practice Address - Fax:901-443-4190
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31324207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3845983Medicaid
TNH06730Medicare UPIN
TN3845983Medicaid