Basic Information
Provider Information | |||||||||
NPI: | 1437569639 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KHATTAB | ||||||||
FirstName: | AHMAD | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 744 W 9TH ST | ||||||||
Address2: |   | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741279020 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9185615701 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 802 S JACKSON AVE STE 410 | ||||||||
Address2: |   | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741279059 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9186318202 | ||||||||
FaxNumber: | 9186318204 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/28/2014 | ||||||||
LastUpdateDate: | 10/19/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/19/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | 6580 | OK | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 200844910A | 05 | OK |   | MEDICAID | 830031 | 01 | OK | MEDICARE | OTHER |