Provider Demographics
NPI:1295755916
Name:KHAIRALLA, ERIC WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:WILLIAM
Last Name:KHAIRALLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ERIC
Other - Middle Name:WILLIAM
Other - Last Name:KHAIRALLAH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9248 WOOD GLADE DR
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066-2209
Mailing Address - Country:US
Mailing Address - Phone:703-438-3033
Mailing Address - Fax:
Practice Address - Street 1:5530 WISCONSIN AVE
Practice Address - Street 2:SUITE 1235
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-4404
Practice Address - Country:US
Practice Address - Phone:301-657-4744
Practice Address - Fax:301-654-9727
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD394512086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDE77263Medicare UPIN
490665Medicare ID - Type Unspecified