Provider Demographics
NPI:1790985596
Name:KHAHAM, MICHAEL (DO, RPH)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:KHAHAM
Suffix:
Gender:M
Credentials:DO, RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3998 FAIR RIDGE DR.
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2921
Mailing Address - Country:US
Mailing Address - Phone:703-295-9360
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:585 SCHENECTADY AVE
Practice Address - Street 2:ANESTHESIA DEPT.
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-1851
Practice Address - Country:US
Practice Address - Phone:718-604-5207
Practice Address - Fax:718-604-5571
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047086183500000X
NY246571207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03224297Medicaid
NYA400028869Medicare PIN
NY03224297Medicaid