Provider Demographics
NPI:1417043811
Name:KARDOONI, KHALIL (MD)
Entity Type:Individual
Prefix:DR
First Name:KHALIL
Middle Name:
Last Name:KARDOONI
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 1:1250 IVES ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601
Mailing Address - Country:US
Mailing Address - Phone:315-782-7330
Mailing Address - Fax:315-782-5773
Practice Address - Street 1:1571 WASHINGTON ST
Practice Address - Street 2:SUITE 107
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-9319
Practice Address - Country:US
Practice Address - Phone:315-782-7330
Practice Address - Fax:315-782-5773
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210462174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01870699Medicaid
NYG47963Medicare UPIN