Provider Demographics
NPI:1093724304
Name:KHAN, KAUSERUZZAMAN A (MD)
Entity Type:Individual
Prefix:
First Name:KAUSERUZZAMAN
Middle Name:A
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 1:3524 E MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-1626
Mailing Address - Country:US
Mailing Address - Phone:608-756-7100
Mailing Address - Fax:608-756-4700
Practice Address - Street 1:3524 E MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-1626
Practice Address - Country:US
Practice Address - Phone:608-756-7100
Practice Address - Fax:608-741-4700
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI45246207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIKHANKAUOtherMERCYCARE INSURANCE
WI34402400Medicaid
WIP00403325CD3624OtherRR MEDICARE
WI000602455Medicare PIN
WIKHANKAUOtherMERCYCARE INSURANCE
WIP00403325CD3624OtherRR MEDICARE