Healthcare Provider Details

I. General information

NPI: 1497173017
Provider Name (Legal Business Name): KHALIL MASABNI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2014
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 AUTO CLUB DR STE 300
DEARBORN MI
48126-2619
US

IV. Provider business mailing address

5250 AUTO CLUB DR STE 300
DEARBORN MI
48126-2619
US

V. Phone/Fax

Practice location:
  • Phone: 520-559-3888
  • Fax:
Mailing address:
  • Phone: 520-559-3888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberEMC0003827
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number88400
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number2024029893
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberME157128
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: