Provider Demographics
NPI:1215435870
Name:KHASHABA LLC
Entity type:Organization
Organization Name:KHASHABA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OMAR
Authorized Official - Middle Name:A
Authorized Official - Last Name:KASHABA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-888-8250
Mailing Address - Street 1:250 N WICKHAM RD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-8625
Mailing Address - Country:US
Mailing Address - Phone:321-752-1571
Mailing Address - Fax:
Practice Address - Street 1:250 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8625
Practice Address - Country:US
Practice Address - Phone:321-752-1517
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-30
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJH488AOtherMEDICARE PTAN
FL024500900Medicaid
FLFY303TOtherMEDICARE - FL
FLDY1649OtherRRMEDICARE PTAN
FL004665600Medicaid