Healthcare Provider Details

I. General information

NPI: 1396902730
Provider Name (Legal Business Name): AHMED S KHALIL MD, RPVI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 01/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8906 135TH ST 2T
JAMAICA NY
11418-2821
US

IV. Provider business mailing address

80 MARCUS DR PROVIDER ENROLLMENT
MELVILLE NY
11747-4230
US

V. Phone/Fax

Practice location:
  • Phone: 718-206-7110
  • Fax: 718-206-7111
Mailing address:
  • Phone: 631-391-8366
  • Fax: 631-454-4161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036-115750
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number249302
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: