Healthcare Provider Details

I. General information

NPI: 1669640165
Provider Name (Legal Business Name): HICHAM KHALLAFI M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2008
Last Update Date: 07/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 KOLBE RD STE 205
LORAIN OH
44053-1677
US

IV. Provider business mailing address

3600 KOLBE RD STE 205
LORAIN OH
44053-1677
US

V. Phone/Fax

Practice location:
  • Phone: 440-960-4416
  • Fax: 440-960-4417
Mailing address:
  • Phone: 440-960-4416
  • Fax: 440-960-4417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number35123425
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License Number35123425
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: