Provider Demographics
NPI:1225252083
Name:KHAIRALLA, TAREQ SULEIMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:TAREQ
Middle Name:SULEIMAN
Last Name:KHAIRALLA
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:PO BOX 17567
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32522-7567
Mailing Address - Country:US
Mailing Address - Phone:850-908-1220
Mailing Address - Fax:850-908-1229
Practice Address - Street 1:1717 N E ST STE 533
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-6365
Practice Address - Country:US
Practice Address - Phone:850-908-1220
Practice Address - Fax:850-908-1229
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301079642207RE0101X
FLME132825207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022045700Medicaid