Provider Demographics
NPI:1396787586
Name:KHALIFA, REDA A (MD)
Entity type:Individual
Prefix:
First Name:REDA
Middle Name:A
Last Name:KHALIFA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1268 LAKE CRESCENT DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-2814
Mailing Address - Country:US
Mailing Address - Phone:248-683-8050
Mailing Address - Fax:248-683-8590
Practice Address - Street 1:3675 HIGHLAND RD
Practice Address - Street 2:SUITE 112
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48328-2326
Practice Address - Country:US
Practice Address - Phone:248-683-8050
Practice Address - Fax:248-683-8590
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2016-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRK072714207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F32730OtherBCBS
MI4757476Medicaid
MIRK072714OtherLICENSE
MIRK072714OtherLICENSE
MI4757476Medicaid