Provider Demographics
NPI:1104320043
Name:KHALIFA, ESAM (MD)
Entity type:Individual
Prefix:
First Name:ESAM
Middle Name:
Last Name:KHALIFA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9508 65TH RD APT 5D
Mailing Address - Street 2:
Mailing Address - City:REGO PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11374-4190
Mailing Address - Country:US
Mailing Address - Phone:727-674-3909
Mailing Address - Fax:
Practice Address - Street 1:1000 W MORENO ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-2316
Practice Address - Country:US
Practice Address - Phone:850-434-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FL148538207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program