Healthcare Provider Details

I. General information

NPI: 1306057450
Provider Name (Legal Business Name): CHRISTIAN G KHAIRALLAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 06/18/2020
Certification Date: 06/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 S WASHINGTON ST - ALTRU PROFESSIONAL CENTER
GRAND FORKS ND
58201
US

IV. Provider business mailing address

2401 DEMERS AVE
GRAND FORKS ND
58201
US

V. Phone/Fax

Practice location:
  • Phone: 701-732-7000
  • Fax:
Mailing address:
  • Phone: 701-780-1891
  • Fax: 419-535-3244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35098474
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number13045
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number4301088399
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: