Provider Demographics
NPI:1982974739
Name:KHALIL, CHAZA (MD)
Entity Type:Individual
Prefix:DR
First Name:CHAZA
Middle Name:
Last Name:KHALIL
Suffix:
Gender:F
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:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:844-362-1735
Mailing Address - Fax:
Practice Address - Street 1:1055 HAMBURG TPKE STE 200
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-3235
Practice Address - Country:US
Practice Address - Phone:973-248-1440
Practice Address - Fax:973-248-1448
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-11
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY265909261Q00000X
NJ25MA09587100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY265909OtherNY STATE LICENSE NUMBER