Provider Demographics
NPI:1366552226
Name:RAZZAQ, KHALID (MD)
Entity type:Individual
Prefix:
First Name:KHALID
Middle Name:
Last Name:RAZZAQ
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 1:1424 STADIUM DRIVE
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701
Mailing Address - Country:US
Mailing Address - Phone:304-327-5710
Mailing Address - Fax:304-327-5781
Practice Address - Street 1:1424 STADIUM DRIVE
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701
Practice Address - Country:US
Practice Address - Phone:304-327-5710
Practice Address - Fax:304-327-5781
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV181952084N0400X
VA01010524902084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
001721810OtherBLUE CROSS BLUE SHIELD
130019067OtherRR MEDICARE
VA007101562Medicaid
WV0090304000Medicaid
001721810OtherBLUE CROSS BLUE SHIELD
WV0090304000Medicaid