Provider Demographics
NPI:1073880936
Name:KHAN, TAHIR A (DPM)
Entity Type:Individual
Prefix:DR
First Name:TAHIR
Middle Name:A
Last Name:KHAN
Suffix:
Gender:M
Credentials:DPM
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 370792
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53237-1892
Mailing Address - Country:US
Mailing Address - Phone:414-808-2911
Mailing Address - Fax:
Practice Address - Street 1:6001 W CENTER ST STE 108
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2154
Practice Address - Country:US
Practice Address - Phone:414-808-2911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1049-25213ES0103X, 213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1049-25OtherWI LICENSE
WI1049-25OtherWI LICENSE