Provider Demographics
NPI:1164454765
Name:KHACHAN, GEORGE (MD,PA)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:
Last Name:KHACHAN
Suffix:
Gender:M
Credentials:MD,PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 BISHOP WALSH RD
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-1806
Mailing Address - Country:US
Mailing Address - Phone:301-724-1151
Mailing Address - Fax:301-724-1894
Practice Address - Street 1:625 KENT AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-3794
Practice Address - Country:US
Practice Address - Phone:301-724-1151
Practice Address - Fax:301-724-1894
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD38971174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD069751600Medicaid
WV3810004421Medicaid
MD069751600Medicaid
WV3810004421Medicaid