Provider Demographics
NPI:1306112305
Name:AL ABDUL RAHEEM, KHALID GHAZI (BS)
Entity type:Individual
Prefix:
First Name:KHALID
Middle Name:GHAZI
Last Name:AL ABDUL RAHEEM
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9993 W NORTH AVE APT 333
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-2510
Mailing Address - Country:US
Mailing Address - Phone:414-581-5626
Mailing Address - Fax:
Practice Address - Street 1:4025 N 92ND ST
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53222-1613
Practice Address - Country:US
Practice Address - Phone:414-358-5431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-24
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI61314207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100034036Medicaid