Provider Demographics
NPI:1053842039
Name:KHAN, ADIBA
Entity Type:Individual
Prefix:
First Name:ADIBA
Middle Name:
Last Name:KHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 E BELVIDERE RD
Mailing Address - Street 2:SUITE 385
Mailing Address - City:GRAYSLAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60030-2012
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1475 E BELVIDERE RD
Practice Address - Street 2:SUITE 385
Practice Address - City:GRAYSLAKE
Practice Address - State:IL
Practice Address - Zip Code:60030-2012
Practice Address - Country:US
Practice Address - Phone:847-535-7157
Practice Address - Fax:312-694-0655
Is Sole Proprietor?:No
Enumeration Date:2017-03-22
Last Update Date:2021-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036151630207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine