Provider Demographics
NPI:1740338417
Name:KHAJA, IBRAHIM A (MD)
Entity type:Individual
Prefix:
First Name:IBRAHIM
Middle Name:A
Last Name:KHAJA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:KHAJA
Other - Middle Name:IBRAHIM
Other - Last Name:A
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3301 W FOREST HOME AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215-2843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1525 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205-2591
Practice Address - Country:US
Practice Address - Phone:414-966-3030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361181782084P0800X
TN416612084P0800X
WI545322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036118178Medicaid