Provider Demographics
NPI:1619105764
Name:ALSABA, KHALED
Entity Type:Individual
Prefix:DR
First Name:KHALED
Middle Name:
Last Name:ALSABA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 COUNTRY CLUB DR NE APT F
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-0917
Mailing Address - Country:US
Mailing Address - Phone:704-787-2193
Mailing Address - Fax:
Practice Address - Street 1:303 COUNTRY CLUB DR NE APT F
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-0917
Practice Address - Country:US
Practice Address - Phone:704-787-2193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-28
Last Update Date:2009-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC96-0113261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCG39700Medicare UPIN