Provider Demographics
NPI:1922070945
Name:KHAWAM, SOUHA (MD)
Entity Type:Individual
Prefix:
First Name:SOUHA
Middle Name:
Last Name:KHAWAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-3109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1935 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-3109
Practice Address - Country:US
Practice Address - Phone:540-387-0441
Practice Address - Fax:540-389-7868
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101-231598207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010099498Medicaid
VA010099498Medicaid
005897C39Medicare PIN
P00164879Medicare PIN