Provider Demographics
NPI:1982262382
Name:KHADER, ALI RAFIQ (MD)
Entity Type:Individual
Prefix:MR
First Name:ALI
Middle Name:RAFIQ
Last Name:KHADER
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 1:32 2ND AVE APT 117
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01803-4435
Mailing Address - Country:US
Mailing Address - Phone:929-289-0959
Mailing Address - Fax:
Practice Address - Street 1:31 BURLINGTON MALL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803-4138
Practice Address - Country:US
Practice Address - Phone:781-744-3753
Practice Address - Fax:781-744-5232
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2020-07-01
Deactivation Date:2020-01-17
Deactivation Code:
Reactivation Date:2020-04-29
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA283247390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program