Basic Information
| Provider Information | |||||||||
| NPI: | 1144588401 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHADBAI | ||||||||
| FirstName: | ADAM | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 933 HILLTOP DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | WEATHERFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760868808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173417670 | ||||||||
| FaxNumber: | 8173417678 | ||||||||
| Practice Location | |||||||||
| Address1: | 933 HILLTOP DR | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | WEATHERFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760868807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173417670 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2012 | ||||||||
| LastUpdateDate: | 02/25/2019 | ||||||||
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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 | 207Q00000X | Q6043 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 354905702 | 05 | TX | MEDICAID |