MEDICARE: MR. KHAMIS TWFIQ KHAMIS ABUZERIQ I

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	09-299-0397	CO

General Provider Information

NPI Number	:	1669955761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KHAMIS TWFIQ KHAMIS ABUZERIQ I

Provider Business Mailing Address
First Line	:	2448 ROCKLIN DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-4319
Country	:	US
Telephone Number	:	505-250-6690
Fax Number	:

Provider Business Practice Location Address
First Line	:	2448 ROCKLIN DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-4319
Country	:	US
Telephone Number	:	505-250-6690
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2018
Last Update Date	:	09/13/2018

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