Provider Demographics
NPI:1760678809
Name:KHALED, MOUNIR (MD)
Entity Type:Individual
Prefix:
First Name:MOUNIR
Middle Name:
Last Name:KHALED
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 1:8944 MACOMB ST
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-2089
Mailing Address - Country:US
Mailing Address - Phone:734-675-0705
Mailing Address - Fax:734-675-0747
Practice Address - Street 1:8944 MACOMB ST
Practice Address - Street 2:
Practice Address - City:GROSSE ILE
Practice Address - State:MI
Practice Address - Zip Code:48138-2089
Practice Address - Country:US
Practice Address - Phone:734-675-0705
Practice Address - Fax:734-675-0747
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-22
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301091157207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1108298981OtherBCBS IND
MI1760678809Medicaid
MI1760678809Medicaid