Provider Demographics
NPI:1285637298
Name:KHAIRA, DIVIS K (MD)
Entity Type:Individual
Prefix:
First Name:DIVIS
Middle Name:K
Last Name:KHAIRA
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 1:5221 PARAMOUNT PKWY STE 420
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27560-5491
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2367
Practice Address - Country:US
Practice Address - Phone:360-414-7878
Practice Address - Fax:360-414-7876
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-00861207R00000X, 207RH0003X
NY319482207RH0003X
WI2648207RH0003X
WAMD60789499207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100098395Medicaid
WYW24590Medicare PIN
WYW24590Medicare PIN
AZ418138Medicaid