Provider Demographics
NPI:1275679755
Name:KHOLOKI, MOHAMED S (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMED
Middle Name:S
Last Name:KHOLOKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:418 SHERWOOD RD
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-1968
Mailing Address - Country:US
Mailing Address - Phone:708-482-3600
Mailing Address - Fax:708-482-3005
Practice Address - Street 1:418 SHERWOOD RD
Practice Address - Street 2:
Practice Address - City:LAGRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-1968
Practice Address - Country:US
Practice Address - Phone:708-482-3600
Practice Address - Fax:708-482-3005
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089463173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG15007Medicare UPIN