Provider Demographics
NPI:1568681740
Name:KHAISER, SHIRAZ (MD)
Entity Type:Individual
Prefix:
First Name:SHIRAZ
Middle Name:
Last Name:KHAISER
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 1:4826 N WEAVERRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61615-8946
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1001 MAIN ST
Practice Address - Street 2:SUITE 500A
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-2038
Practice Address - Country:US
Practice Address - Phone:309-672-4980
Practice Address - Fax:309-671-2979
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 104853207R00000X
IL036134402207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine