Provider Demographics
NPI:1376393645
Name:KHASRACHI, AMMAR
Entity Type:Individual
Prefix:
First Name:AMMAR
Middle Name:
Last Name:KHASRACHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3353 DETROIT ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4157
Mailing Address - Country:US
Mailing Address - Phone:218-790-7159
Mailing Address - Fax:
Practice Address - Street 1:3353 DETROIT ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4157
Practice Address - Country:US
Practice Address - Phone:218-790-7159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2080P0205X2080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology