Provider Demographics
NPI:1407830292
Name:KIFAYATULLAH, KHAWAJA (MD)
Entity Type:Individual
Prefix:MR
First Name:KHAWAJA
Middle Name:
Last Name:KIFAYATULLAH
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 1:8355 NORTHCLIFFE BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:FL
Mailing Address - Zip Code:34606-1139
Mailing Address - Country:US
Mailing Address - Phone:352-684-2929
Mailing Address - Fax:352-684-2646
Practice Address - Street 1:8355 NORTHCLIFFE BLVD
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34606-1139
Practice Address - Country:US
Practice Address - Phone:352-684-2929
Practice Address - Fax:352-684-2646
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 87059207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI35084Medicare UPIN