Provider Demographics
NPI:1326074386
Name:KHALILI, MARK H (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:H
Last Name:KHALILI
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 1:835 SWEITZER ST
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45331-1007
Mailing Address - Country:US
Mailing Address - Phone:937-548-1141
Mailing Address - Fax:
Practice Address - Street 1:835 SWEITZER ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-1007
Practice Address - Country:US
Practice Address - Phone:937-548-1141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35079468207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3903304OtherUHC CCC
OH3920481OtherUHC ER
OH000000342339OtherANTHEM ER
OH1995899500OtherBWC
OH000000342356OtherANTHEM CCC
OH2300790Medicaid
OH3903304OtherUHC CCC
OH000000342356OtherANTHEM CCC
OH3920481OtherUHC ER