Provider Demographics
NPI:1205418829
Name:KHAZAAL, JAWAD RADWAN
Entity Type:Individual
Prefix:
First Name:JAWAD
Middle Name:RADWAN
Last Name:KHAZAAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22920 HOLLANDER ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48128-1369
Mailing Address - Country:US
Mailing Address - Phone:313-729-9862
Mailing Address - Fax:
Practice Address - Street 1:6400 FANNIN ST STE 2800
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1534
Practice Address - Country:US
Practice Address - Phone:313-729-9862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-22
Last Update Date:2022-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program