Provider Demographics
NPI:1609194653
Name:KHALILI, HAMID-U-RAHMAN (ARNP)
Entity Type:Individual
Prefix:MR
First Name:HAMID-U-RAHMAN
Middle Name:
Last Name:KHALILI
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44008
Mailing Address - Street 2:UFJP - PROVIDER ENROLLMENT
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32231-4008
Mailing Address - Country:US
Mailing Address - Phone:904-244-3199
Mailing Address - Fax:904-244-3425
Practice Address - Street 1:5045 SOUTEL DR STE 12
Practice Address - Street 2:UFJAX - SOUTEL PLAZA FAMILY PRACTICE
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32208-1885
Practice Address - Country:US
Practice Address - Phone:904-633-0500
Practice Address - Fax:904-633-0441
Is Sole Proprietor?:No
Enumeration Date:2010-05-13
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9251167363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0031248-00Medicaid
FLEO442ZMedicare PIN
FLEO442YMedicare PIN
FL0031248-00Medicaid