Provider Demographics
NPI:1508807389
Name:KHALILI, MOHAMMAD FAZEL (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:FAZEL
Last Name:KHALILI
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 1:105 S BRYANT AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-6399
Mailing Address - Country:US
Mailing Address - Phone:405-340-4565
Mailing Address - Fax:405-340-4583
Practice Address - Street 1:105 S BRYANT AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6399
Practice Address - Country:US
Practice Address - Phone:405-340-4565
Practice Address - Fax:405-340-4583
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23879207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK23879OtherMEDICAL LICENSE
OKI23689Medicare UPIN