Provider Demographics
NPI:1023190469
Name:KHAN, SUPRIYA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUPRIYA
Middle Name:
Last Name:KHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUPRIYA
Other - Middle Name:
Other - Last Name:MADDIRALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1840 E RAY RD
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85225-8720
Mailing Address - Country:US
Mailing Address - Phone:855-397-0197
Mailing Address - Fax:800-272-6512
Practice Address - Street 1:1547 NE 40TH AVE STE B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1862
Practice Address - Country:US
Practice Address - Phone:503-284-1937
Practice Address - Fax:503-284-3908
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60054413207RN0300X
KY54992207RN0300X
ORMD 28660207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1090617Medicaid
OR276227Medicaid
FL2767538-00Medicaid
GA605563581AMedicaid
FLAA293ZMedicare PIN