Provider Demographics
NPI:1497173017
Name:MASABNI, KHALIL (MD)
Entity type:Individual
Prefix:
First Name:KHALIL
Middle Name:
Last Name:MASABNI
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 1:5250 AUTO CLUB DR STE 300
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2619
Mailing Address - Country:US
Mailing Address - Phone:520-559-3888
Mailing Address - Fax:
Practice Address - Street 1:5250 AUTO CLUB DR STE 300
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2619
Practice Address - Country:US
Practice Address - Phone:520-559-3888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-01
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIEMC00038272086S0129X
GA884002086S0129X
MO20240298932086S0129X
FLME1571282086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200145538Medicaid