Provider Demographics
NPI:1518961879
Name:SHUKAIRY, KHALED M (MD)
Entity Type:Individual
Prefix:DR
First Name:KHALED
Middle Name:M
Last Name:SHUKAIRY
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 1:1501 S CENTER RD
Mailing Address - Street 2:BLDG B
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-1731
Mailing Address - Country:US
Mailing Address - Phone:810-742-0225
Mailing Address - Fax:810-742-7990
Practice Address - Street 1:1501 S CENTER RD
Practice Address - Street 2:BLDG B
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1731
Practice Address - Country:US
Practice Address - Phone:810-742-0225
Practice Address - Fax:810-742-7990
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-02
Last Update Date:2011-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301037118207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2126594Medicaid
02501435042Medicare ID - Type Unspecified
MI2126594Medicaid