Provider Demographics
NPI:1750796629
Name:SONBOL, KHALID M (MD)
Entity type:Individual
Prefix:
First Name:KHALID
Middle Name:M
Last Name:SONBOL
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 1:1200 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2736
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:320-656-7115
Practice Address - Street 1:1406 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1901
Practice Address - Country:US
Practice Address - Phone:612-205-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036141429207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL214881OtherMEDICARE GROUP PTAN