Provider Demographics
NPI:1073509253
Name:KHAWAJA, IMRAN SHUJA (MD)
Entity Type:Individual
Prefix:DR
First Name:IMRAN
Middle Name:SHUJA
Last Name:KHAWAJA
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:PO BOX 93685
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-0116
Mailing Address - Country:US
Mailing Address - Phone:817-722-6078
Mailing Address - Fax:817-722-6077
Practice Address - Street 1:823 IRA E WOODS AVE STE 200
Practice Address - Street 2:
Practice Address - City:GRAPEVINE
Practice Address - State:TX
Practice Address - Zip Code:76051
Practice Address - Country:US
Practice Address - Phone:817-722-6078
Practice Address - Fax:817-722-6077
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP68472084S0012X, 2084N0400X
MN436902084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAENROLLEDMedicaid
MNHP34234OtherHEALTHPARTNERS
MN260048415OtherRAILROAD MEDICARE
MN964688400Medicaid
MN15-63744OtherUNITED BEHAVIORAL HEALTH
MN51D81KHOtherBLUE CROSS BLUE SHIELD MN
MN167606OtherUCARE MN
MN1029250OtherPREFERREDONE
WI35343100Medicaid
MN290000582Medicare PIN
MNH42486Medicare UPIN
IAENROLLEDMedicaid