Provider Demographics
NPI:1669467726
Name:KHERALLAH, NIZAR (MD)
Entity Type:Individual
Prefix:DR
First Name:NIZAR
Middle Name:
Last Name:KHERALLAH
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 1:530 NE GLEN OAK AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61637-0001
Mailing Address - Country:US
Mailing Address - Phone:309-624-4542
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE DEPT OF
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-2673
Practice Address - Country:US
Practice Address - Phone:309-624-9844
Practice Address - Fax:309-624-9844
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350726482080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric Pulmonology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2122661Medicaid