Provider Demographics
NPI:1306502026
Name:SMITH, KHADEEJA (DC)
Entity type:Individual
Prefix:
First Name:KHADEEJA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14420 W SIDE BLVD APT 304
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-6270
Mailing Address - Country:US
Mailing Address - Phone:516-402-0174
Mailing Address - Fax:
Practice Address - Street 1:8855 ANNAPOLIS RD STE 112
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-2962
Practice Address - Country:US
Practice Address - Phone:301-284-8869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDS04086111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty