Basic Information
| Provider Information | |||||||||
| NPI: | 1396902730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHALIL | ||||||||
| FirstName: | AHMED | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD, RPVI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 MARCUS DR | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117474230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313918366 | ||||||||
| FaxNumber: | 6314544161 | ||||||||
| Practice Location | |||||||||
| Address1: | 8906 135TH ST | ||||||||
| Address2: | 2T | ||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114182821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182067110 | ||||||||
| FaxNumber: | 7182067111 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2008 | ||||||||
| LastUpdateDate: | 01/17/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 036-115750 | IL | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | 249302 | NY | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 03022373 | 05 | NY | MEDICAID |