Provider Demographics
NPI:1073588943
Name:KHAN, AZMATHULLAH (MD)
Entity Type:Individual
Prefix:DR
First Name:AZMATHULLAH
Middle Name:
Last Name:KHAN
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 1:4700 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4124
Mailing Address - Country:US
Mailing Address - Phone:313-945-6100
Mailing Address - Fax:313-945-5260
Practice Address - Street 1:4700 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4124
Practice Address - Country:US
Practice Address - Phone:313-945-6100
Practice Address - Fax:313-945-5260
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAK065422208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4534739Medicaid
MIG36156Medicare UPIN