Provider Demographics
NPI:1932147477
Name:ALBASHA, KHALED (MD)
Entity Type:Individual
Prefix:
First Name:KHALED
Middle Name:
Last Name:ALBASHA
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 1:3505 S MERCY RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-0427
Mailing Address - Country:US
Mailing Address - Phone:480-612-2007
Mailing Address - Fax:
Practice Address - Street 1:3505 S MERCY RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-0427
Practice Address - Country:US
Practice Address - Phone:480-786-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29384207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ620212Medicaid
AZ620212Medicaid
AZ102940Medicare PIN
AZ67774Medicare ID - Type Unspecified