Healthcare Provider Details

I. General information

NPI: 1376698829
Provider Name (Legal Business Name): AMRULLAH KHELGHATI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9305 MAIN ST SUITE D
ZACHARY LA
70791-7441
US

IV. Provider business mailing address

9305 MAIN ST SUITE D
ZACHARY LA
70791-7441
US

V. Phone/Fax

Practice location:
  • Phone: 225-654-0300
  • Fax: 225-654-0102
Mailing address:
  • Phone: 225-654-0300
  • Fax: 225-654-0102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number05611R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: