Provider Demographics
NPI:1265457071
Name:KHALAFI, S M REZA (MD)
Entity Type:Individual
Prefix:
First Name:S M
Middle Name:REZA
Last Name:KHALAFI
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 1:900 W ROSEDALE ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-4681
Mailing Address - Country:US
Mailing Address - Phone:817-885-7442
Mailing Address - Fax:817-885-7443
Practice Address - Street 1:900 W ROSEDALE ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4681
Practice Address - Country:US
Practice Address - Phone:817-885-7442
Practice Address - Fax:817-885-7443
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ7032208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00292548OtherRAILROAD MEDICARE
TX115815604Medicaid