Provider Demographics
NPI:1174068720
Name:KHALLAF, MOHAMED
Entity type:Individual
Prefix:
First Name:MOHAMED
Middle Name:
Last Name:KHALLAF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 JULIANAS WAY
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-7182
Mailing Address - Country:US
Mailing Address - Phone:646-436-8480
Mailing Address - Fax:
Practice Address - Street 1:6805 FRESH POND RD
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-5200
Practice Address - Country:US
Practice Address - Phone:718-456-2543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-05
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1345001225100000X
2251G0304X, 2251H1300X, 2251X0800X, 225100000X
NY0368562251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics
No2251H1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHuman Factors
No2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic