Provider Demographics
NPI:1710967674
Name:KHATIB, BASEL (MD)
Entity Type:Individual
Prefix:DR
First Name:BASEL
Middle Name:
Last Name:KHATIB
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 1:5728 SCHAEFER RD STE 101
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2287
Mailing Address - Country:US
Mailing Address - Phone:313-624-3005
Mailing Address - Fax:313-846-4547
Practice Address - Street 1:5728 SCHAEFER RD STE 101
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2287
Practice Address - Country:US
Practice Address - Phone:313-624-3005
Practice Address - Fax:313-846-4547
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058311208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4305600Medicaid
MIF99464Medicare UPIN