Provider Demographics
NPI:1407206790
Name:KHALIL, WISAM (MD)
Entity Type:Individual
Prefix:DR
First Name:WISAM
Middle Name:
Last Name:KHALIL
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 1:3769 AUDREY RAE LN
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-6604
Mailing Address - Country:US
Mailing Address - Phone:248-796-2383
Mailing Address - Fax:
Practice Address - Street 1:7575 GRAND RIVER RD STE 209
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-9379
Practice Address - Country:US
Practice Address - Phone:810-844-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program