Provider Demographics
NPI:1164264784
Name:KHALUS, IVANNA (SA-C, MD)
Entity type:Individual
Prefix:
First Name:IVANNA
Middle Name:
Last Name:KHALUS
Suffix:
Gender:F
Credentials:SA-C, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 W RAND RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60004-3142
Mailing Address - Country:US
Mailing Address - Phone:847-215-0530
Mailing Address - Fax:847-818-8640
Practice Address - Street 1:129 W RAND RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-3142
Practice Address - Country:US
Practice Address - Phone:847-215-0530
Practice Address - Fax:847-818-8640
Is Sole Proprietor?:No
Enumeration Date:2024-06-12
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238000812208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery