Provider Demographics
NPI:1184687014
Name:KHAMOUSIA, NIDAA (MD)
Entity Type:Individual
Prefix:DR
First Name:NIDAA
Middle Name:
Last Name:KHAMOUSIA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6450 WHEATSTONE CT
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-9402
Mailing Address - Country:US
Mailing Address - Phone:419-866-6200
Mailing Address - Fax:419-866-7170
Practice Address - Street 1:6450 WHEATSTONE CT
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-9402
Practice Address - Country:US
Practice Address - Phone:419-866-6200
Practice Address - Fax:419-866-7170
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35087356207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2633396Medicaid
OH2633396Medicaid
OKH314930Medicare PIN