Provider Demographics
NPI:1467671677
Name:KHALIQ, FAZILA (MD)
Entity Type:Individual
Prefix:DR
First Name:FAZILA
Middle Name:
Last Name:KHALIQ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:7601 SOUTHCREST PARKWAY
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671
Practice Address - Country:US
Practice Address - Phone:662-772-2980
Practice Address - Fax:662-772-2960
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-14405207R00000X
TN49063207R00000X
MS21279207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03032215Medicaid
TN1533216Medicaid
AR215115001Medicaid
MS03032215Medicaid