Basic Information
| Provider Information | |||||||||
| NPI: | 1124016829 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHIRFAN | ||||||||
| FirstName: | MOHAMED | ||||||||
| MiddleName: | WAEL J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2510 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852142510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6024320146 | ||||||||
| FaxNumber: | 4808219555 | ||||||||
| Practice Location | |||||||||
| Address1: | 24044 HIGHWAY 59 N | ||||||||
| Address2: | |||||||||
| City: | KINGWOOD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773391500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2816747812 | ||||||||
| FaxNumber: | 2813106602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 08/12/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 34498 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 967250 | 05 | AZ | MEDICAID |