Provider Demographics
NPI:1790149300
Name:KHALAF, MAHMOUD
Entity Type:Individual
Prefix:
First Name:MAHMOUD
Middle Name:
Last Name:KHALAF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12129 RR 620 N STE 610
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-1086
Mailing Address - Country:US
Mailing Address - Phone:512-900-7800
Mailing Address - Fax:
Practice Address - Street 1:12129 RR 620 N STE 610
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-1086
Practice Address - Country:US
Practice Address - Phone:512-900-7800
Practice Address - Fax:833-463-1693
Is Sole Proprietor?:No
Enumeration Date:2016-04-09
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD469360207R00000X
NJ25MA10541100207R00000X
TXT1118207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1790149300Medicaid
PA1790149300OtherNPI