Provider Demographics
NPI:1588930242
Name:KHALIFA, ALI (MD)
Entity type:Individual
Prefix:DR
First Name:ALI
Middle Name:
Last Name:KHALIFA
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 1:800 E DAWSON ST # 2
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2036
Mailing Address - Country:US
Mailing Address - Phone:190-353-1450
Mailing Address - Fax:
Practice Address - Street 1:800 E DAWSON ST # 2
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2036
Practice Address - Country:US
Practice Address - Phone:903-531-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ8084207L00000X, 207RC0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX75-2616977-042OtherTRICARE
TXP01878844OtherMEDICARE RAIL ROAD
TX587381ZGX7OtherMEDICARE