Provider Demographics
NPI:1205099553
Name:KHALID, EJAZ
Entity type:Individual
Prefix:DR
First Name:EJAZ
Middle Name:
Last Name:KHALID
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 1:75 HOCKANUM BLVD
Mailing Address - Street 2:UNIT 3512
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066
Mailing Address - Country:US
Mailing Address - Phone:312-307-0027
Mailing Address - Fax:
Practice Address - Street 1:759 CHEST NUT STREET
Practice Address - Street 2:DEPARTMENT OF INTERNAL MEDICINE ATTN LINDA BAILLARGEON
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01199
Practice Address - Country:US
Practice Address - Phone:413-794-4373
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-08
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA237718207R00000X
UT10385750-1205208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist