Provider Demographics
NPI:1811039266
Name:ABUMAYALEH, KHALED OTHMAN (OD)
Entity Type:Individual
Prefix:DR
First Name:KHALED
Middle Name:OTHMAN
Last Name:ABUMAYALEH
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 FOX LANDING LANE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37922
Mailing Address - Country:US
Mailing Address - Phone:865-671-6127
Mailing Address - Fax:
Practice Address - Street 1:1030 HUNTERS CROSSING LANE
Practice Address - Street 2:
Practice Address - City:ALCOA
Practice Address - State:TN
Practice Address - Zip Code:37701
Practice Address - Country:US
Practice Address - Phone:865-984-1100
Practice Address - Fax:865-984-8305
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1848152W00000X
GA1827152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1847OtherTN LICENSE
3942602Medicare ID - Type Unspecified
TN1847OtherTN LICENSE