Basic Information
| Provider Information | |||||||||
| NPI: | 1952334955 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALY | ||||||||
| FirstName: | KHALID | ||||||||
| MiddleName: | SAAD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ABDEL-GAWAD | ||||||||
| OtherFirstName: | KHALID | ||||||||
| OtherMiddleName: | SAAD | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 562 S ELLIOTT ST | ||||||||
| Address2: | |||||||||
| City: | PRYOR | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743616411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188248000 | ||||||||
| FaxNumber: | 9188255505 | ||||||||
| Practice Location | |||||||||
| Address1: | 562 S ELLIOTT ST | ||||||||
| Address2: | |||||||||
| City: | PRYOR | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743616411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188248000 | ||||||||
| FaxNumber: | 9188255505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 05/01/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 20428 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100226700A | 05 | OK | MEDICAID |