Basic Information
| Provider Information | |||||||||
| NPI: | 1669563342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHABBAZ | ||||||||
| FirstName: | WALID | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2022 KELLE DR | ||||||||
| Address2: | |||||||||
| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463048708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2193643616 | ||||||||
| FaxNumber: | 2133643610 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 E US HIGHWAY 6 STE 310 | ||||||||
| Address2: | |||||||||
| City: | VALPARAISO | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199836380 | ||||||||
| FaxNumber: | 2199836080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2006 | ||||||||
| LastUpdateDate: | 09/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 010-51874 | IN | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 200262960 | 05 | IN | MEDICAID |