Provider Demographics
NPI:1841272721
Name:KHADER, SYED ABDUL (DPM)
Entity type:Individual
Prefix:DR
First Name:SYED
Middle Name:ABDUL
Last Name:KHADER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4612 OUTER LOOP
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-3971
Mailing Address - Country:US
Mailing Address - Phone:502-804-4811
Mailing Address - Fax:
Practice Address - Street 1:3045 RING RD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-7933
Practice Address - Country:US
Practice Address - Phone:270-737-3338
Practice Address - Fax:270-765-5666
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000994A213E00000X, 213ES0103X, 213ES0103X
KY243933213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY80000599Medicaid
IN200522380Medicaid
KY50022120OtherPASSPORT
KY3691896000OtherPASSPORT ADVANTAGE
000000590059OtherANTHEM
KY80000599Medicaid
KYP00853998Medicare PIN
IN258420AMedicare PIN
KY00811001Medicare PIN