1073044186 NPI number — DR. KHALED DEEB MD, PHD, MBA

Table of content: DR. KHALED DEEB MD, PHD, MBA (NPI 1073044186)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073044186 NPI number — DR. KHALED DEEB MD, PHD, MBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DEEB
Provider First Name:
KHALED
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD, PHD, MBA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073044186
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6813 FINAMORE CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE WORTH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33467-8727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-483-3381
Provider Business Mailing Address Fax Number:
954-516-0720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 HOLLYWOOD BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33019-1608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-483-3381
Provider Business Practice Location Address Fax Number:
954-516-0720
Provider Enumeration Date:
03/22/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  141889 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: ME141889 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: ME141889 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110362700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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