Provider Demographics
NPI:1194778159
Name:KHADRA, ABDUL M (MD)
Entity type:Individual
Prefix:DR
First Name:ABDUL
Middle Name:M
Last Name:KHADRA
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 1:954 WESTFIELD ST
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-3809
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:954 WESTFIELD ST
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089-3809
Practice Address - Country:US
Practice Address - Phone:413-733-2127
Practice Address - Fax:413-733-2128
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA37593207R00000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA037593OtherTUFTS
MA13575OtherHEALTH NEW ENGLAND
MA3002233Medicaid
MAH22028OtherBCBS
MA798624OtherCONNECTICARE
MA037593OtherSECURE HORIZONS
MA100064OtherCIGNA
MA566945OtherUS HEALTHCARE
MA4411111942OtherRAILROAD MEDICARE
MA566945OtherUS HEALTHCARE
MAH22028Medicare ID - Type Unspecified