Provider Demographics
NPI:1982054078
Name:KHALIL, DIANA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
Last Name:KHALIL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9560
Mailing Address - Fax:239-343-9624
Practice Address - Street 1:13681 DOCTORS WAY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4300
Practice Address - Country:US
Practice Address - Phone:239-343-7652
Practice Address - Fax:239-343-0533
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2024-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME145167207RH0002X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106163200Medicaid