Provider Demographics
NPI:1740803279
Name:KHALIL, ISSA (NAVY IDC)
Entity Type:Individual
Prefix:
First Name:ISSA
Middle Name:
Last Name:KHALIL
Suffix:
Gender:M
Credentials:NAVY IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1803 TALMADGE DR UNIT 9
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-2317
Mailing Address - Country:US
Mailing Address - Phone:619-379-4026
Mailing Address - Fax:
Practice Address - Street 1:USS DONALD COOK
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09566
Practice Address - Country:US
Practice Address - Phone:619-379-4026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman