Provider Demographics
NPI:1114579554
Name:KHAN, NABA RAZI (OD)
Entity Type:Individual
Prefix:
First Name:NABA
Middle Name:RAZI
Last Name:KHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 COATES BLUFF DR APT 918
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2859
Mailing Address - Country:US
Mailing Address - Phone:214-543-4019
Mailing Address - Fax:
Practice Address - Street 1:9924 KENNERLY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-2704
Practice Address - Country:US
Practice Address - Phone:314-842-5858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-16
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1890-826AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty