Provider Demographics
NPI:1265545511
Name:KHALIFA, FEDWA (MD)
Entity type:Individual
Prefix:DR
First Name:FEDWA
Middle Name:
Last Name:KHALIFA
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:PO BOX 6524
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63006-6524
Mailing Address - Country:US
Mailing Address - Phone:314-432-2580
Mailing Address - Fax:314-432-0223
Practice Address - Street 1:930 KINGSCOVE CT
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-8350
Practice Address - Country:US
Practice Address - Phone:314-289-6636
Practice Address - Fax:636-778-9068
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO200200823207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO14009OtherESSANCE
MO199157OtherBLUE CROSS BLUE SHIELD
MOH78529OtherMERCY
MO55895OtherHCUSA
MO699445OtherHEALTHLINK
MO227478OtherGHP
MO990100236Medicare PIN
MOH78529OtherMERCY