Provider Demographics
NPI:1669442505
Name:KHASILEVA, VERA (MD05)
Entity Type:Individual
Prefix:DR
First Name:VERA
Middle Name:
Last Name:KHASILEVA
Suffix:
Gender:F
Credentials:MD05
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6530 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3216
Mailing Address - Country:US
Mailing Address - Phone:248-661-8240
Mailing Address - Fax:313-562-2216
Practice Address - Street 1:6530 FARMINGTON RD
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3216
Practice Address - Country:US
Practice Address - Phone:248-661-8240
Practice Address - Fax:313-562-2216
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIVK068541207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110247579OtherMEDICARE RAILROAD
MI700H219330OtherBCBSM
MI4596642Medicaid
MI7358063OtherAETNA
MIVK068541OtherSTATE LICENSE
MI7358063OtherAETNA
MIVK068541OtherSTATE LICENSE