Healthcare Provider Details

I. General information

NPI: 1104320043
Provider Name (Legal Business Name): ESAM KHALIFA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2018
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 GULF BREEZE PKWY
GULF BREEZE FL
32561-4897
US

IV. Provider business mailing address

9508 65TH RD APT 5D
REGO PARK NY
11374-4190
US

V. Phone/Fax

Practice location:
  • Phone: 850-934-2000
  • Fax:
Mailing address:
  • Phone: 727-674-3909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME148538
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: