Provider Demographics
NPI:1154161438
Name:EL-KHATIB, SAMANTHA (OD)
Entity type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:EL-KHATIB
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4560 CURTIS ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2837
Mailing Address - Country:US
Mailing Address - Phone:313-870-8033
Mailing Address - Fax:
Practice Address - Street 1:13530 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-3574
Practice Address - Country:US
Practice Address - Phone:313-827-0779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-25
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901005801152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist