Provider Demographics
NPI:1669955761
Name:ABUZERIQ, KHAMIS TWFIQ KHAMIS I
Entity type:Individual
Prefix:MR
First Name:KHAMIS
Middle Name:TWFIQ KHAMIS
Last Name:ABUZERIQ
Suffix:I
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:ISSAM
Other - Middle Name:OMAR
Other - Last Name:SAMARA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:WALA HEALTH TRANSPOR
Mailing Address - Street 1:2448 ROCKLIN DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-4319
Mailing Address - Country:US
Mailing Address - Phone:505-250-6690
Mailing Address - Fax:
Practice Address - Street 1:2448 ROCKLIN DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80915-4319
Practice Address - Country:US
Practice Address - Phone:505-250-6690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO09-299-0397172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver