Basic Information
| Provider Information | |||||||||
| NPI: | 1659802544 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHALEEFAH | ||||||||
| FirstName: | MUNTADHER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5200 COMMERCE CROSSINGS DR FL 3 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402292182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5022534924 | ||||||||
| FaxNumber: | 5024895750 | ||||||||
| Practice Location | |||||||||
| Address1: | 3900 KRESGE WAY STE 56 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402074683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5028957265 | ||||||||
| FaxNumber: | 5028972032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2017 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084N0400X | 54929 | KY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
No ID Information.