Provider Demographics
NPI:1871557389
Name:KHADEEJA, THARAYIL (MD)
Entity type:Individual
Prefix:DR
First Name:THARAYIL
Middle Name:
Last Name:KHADEEJA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8229 LAKE CREST DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-6754
Mailing Address - Country:US
Mailing Address - Phone:734-709-3750
Mailing Address - Fax:
Practice Address - Street 1:23077 GREENFIELD RD
Practice Address - Street 2:SUITE 253
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3709
Practice Address - Country:US
Practice Address - Phone:248-559-5950
Practice Address - Fax:248-559-2103
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301058445208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics