Provider Demographics
NPI:1467464214
Name:WAKIM, KHALIL G
Entity type:Individual
Prefix:
First Name:KHALIL
Middle Name:G
Last Name:WAKIM
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 1:2001 N GRANVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303-2110
Mailing Address - Country:US
Mailing Address - Phone:765-284-0493
Mailing Address - Fax:765-284-2434
Practice Address - Street 1:2101 JACKSON ST
Practice Address - Street 2:# 105
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-4388
Practice Address - Country:US
Practice Address - Phone:765-649-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2008-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01028183A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
506030Medicare ID - Type Unspecified
B29139Medicare UPIN