Provider Demographics
NPI:1821012113
Name:KHALIL, TAHER (M D P A)
Entity Type:Individual
Prefix:
First Name:TAHER
Middle Name:
Last Name:KHALIL
Suffix:
Gender:M
Credentials:M D P A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 HAND AVE
Mailing Address - Street 2:SUITE K
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-5063
Mailing Address - Country:US
Mailing Address - Phone:386-673-5404
Mailing Address - Fax:386-673-5480
Practice Address - Street 1:1425 HAND AVE
Practice Address - Street 2:SUITE K
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-1135
Practice Address - Country:US
Practice Address - Phone:386-673-5404
Practice Address - Fax:386-673-5480
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81508207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL3165111OtherCIGNA
FL264363400Medicaid
FL78667OtherBLUECROSS OF FLORIDA
FL7902546OtherAETNA
FL78667OtherBLUECROSS OF FLORIDA
FL3165111OtherCIGNA