Provider Demographics
NPI:1336289958
Name:KHALILI, MICHAEL M (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:M
Last Name:KHALILI
Suffix:
Gender:M
Credentials:DO
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 491262
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-9262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1414 S GRAND AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90015-3067
Practice Address - Country:US
Practice Address - Phone:213-259-0608
Practice Address - Fax:213-259-0618
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6771207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX67710Medicaid
CA20A6771AMedicare ID - Type Unspecified
CA00AX67710Medicaid