Provider Demographics
NPI:1649924986
Name:KOTB, KHALED
Entity type:Individual
Prefix:
First Name:KHALED
Middle Name:
Last Name:KOTB
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 1:2644 CUSTER PKWY APT D
Mailing Address - Street 2:
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-1628
Mailing Address - Country:US
Mailing Address - Phone:347-702-0727
Mailing Address - Fax:
Practice Address - Street 1:3411 CUSTER PKWY
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-1012
Practice Address - Country:US
Practice Address - Phone:972-470-1372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69992183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist