Provider Demographics
NPI:1518589894
Name:KHALIL, LAITH (DO)
Entity Type:Individual
Prefix:
First Name:LAITH
Middle Name:
Last Name:KHALIL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27372 MICHELE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48127-1809
Mailing Address - Country:US
Mailing Address - Phone:313-977-2226
Mailing Address - Fax:
Practice Address - Street 1:3031 W GRAND BLVD STE 600
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3014
Practice Address - Country:US
Practice Address - Phone:313-346-5235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-10
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101026620207Q00000X, 208D00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program