Provider Demographics
NPI:1619497005
Name:KHALILI, SHIVA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIVA
Middle Name:
Last Name:KHALILI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 CHICAGO AVE APT 3302
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79414-6006
Mailing Address - Country:US
Mailing Address - Phone:818-416-2614
Mailing Address - Fax:
Practice Address - Street 1:3601 4TH ST. MS 6211
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79414-7941
Practice Address - Country:US
Practice Address - Phone:806-743-3039
Practice Address - Fax:806-743-2174
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2017-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10059614390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program