Provider Demographics
NPI:1205818911
Name:KHAN, DASTAGIR ALAM (MD)
Entity Type:Individual
Prefix:DR
First Name:DASTAGIR
Middle Name:ALAM
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 1:27 DYKE RD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-1237
Mailing Address - Country:US
Mailing Address - Phone:904-955-7190
Mailing Address - Fax:
Practice Address - Street 1:27 DYKE RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1237
Practice Address - Country:US
Practice Address - Phone:904-955-7190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY281049208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04290768Medicaid
FL270290800Medicaid
NY04290768Medicaid
FLF90152Medicare UPIN