Provider Demographics
NPI:1083985873
Name:GOHAR S. KHAN, M.D., P,A.
Entity Type:Organization
Organization Name:GOHAR S. KHAN, M.D., P,A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:DEDE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEBENALER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:386-767-9000
Mailing Address - Street 1:905 BEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH DAYTONA
Mailing Address - State:FL
Mailing Address - Zip Code:32119-1705
Mailing Address - Country:US
Mailing Address - Phone:386-767-9000
Mailing Address - Fax:386-767-3761
Practice Address - Street 1:905 BEVILLE RD
Practice Address - Street 2:
Practice Address - City:SOUTH DAYTONA
Practice Address - State:FL
Practice Address - Zip Code:32119-1705
Practice Address - Country:US
Practice Address - Phone:386-767-9000
Practice Address - Fax:386-767-3761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0029698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL254205600Medicaid
FL254205600Medicaid