Provider Demographics
NPI:1356370910
Name:KHASAWNEH, KHALED RIAD (MD)
Entity type:Individual
Prefix:
First Name:KHALED
Middle Name:RIAD
Last Name:KHASAWNEH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KHALED
Other - Middle Name:RIAD
Other - Last Name:AL-KHASAWNEH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4301 W. MARKHAM, SLOT #783
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205
Mailing Address - Country:US
Mailing Address - Phone:501-686-8000
Mailing Address - Fax:
Practice Address - Street 1:4301 W. MARKHAM, SLOT #783
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205
Practice Address - Country:US
Practice Address - Phone:501-686-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2016-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-4692207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100076780Medicaid
ARE-4692OtherLICENSE NUMBER
VAP00733560OtherRAILROAD MEDICARE
VAC10456OtherTRAILBLAZER
VA0101245603OtherSTATE LICENSE
VA1356370910Medicaid
KY7100076780Medicaid