Provider Demographics
NPI:1487603239
Name:KHADRA, SUHAIL H (MD)
Entity type:Individual
Prefix:
First Name:SUHAIL
Middle Name:H
Last Name:KHADRA
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 1:10010 DONALD POWERS DR
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321
Mailing Address - Country:US
Mailing Address - Phone:219-934-4210
Mailing Address - Fax:219-934-4288
Practice Address - Street 1:10010 DONALD POWERS DR
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321
Practice Address - Country:US
Practice Address - Phone:219-934-4210
Practice Address - Fax:219-934-4288
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-09
Last Update Date:2015-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036066290207R00000X, 207RC0000X
IN01075981A193400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes193400000XGroupSingle Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE19020Medicare UPIN
IL906200Medicare ID - Type Unspecified