Healthcare Provider Details

I. General information

NPI: 1619105475
Provider Name (Legal Business Name): KHALID HESHAM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 08/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 CLARKSON AVE MSC 30
BROOKLYN NY
11203-2012
US

IV. Provider business mailing address

450 CLARKSON AVE MSC 30
BROOKLYN NY
11203-2012
US

V. Phone/Fax

Practice location:
  • Phone: 718-270-7364
  • Fax:
Mailing address:
  • Phone: 718-270-7364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XP3100X
TaxonomyPediatric Orthopaedic Surgery Physician
License Number280344
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: