Provider Demographics
NPI:1407512619
Name:KHALIL, ABBAS
Entity Type:Individual
Prefix:
First Name:ABBAS
Middle Name:
Last Name:KHALIL
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 1:23874 KEAN ST STE 140
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1851
Mailing Address - Country:US
Mailing Address - Phone:313-791-7976
Mailing Address - Fax:313-757-7652
Practice Address - Street 1:23874 KEAN ST STE 140
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1851
Practice Address - Country:US
Practice Address - Phone:313-791-7976
Practice Address - Fax:313-757-7652
Is Sole Proprietor?:No
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver