Provider Demographics
NPI:1235126731
Name:KHAN, KASSIM A (MD)
Entity Type:Individual
Prefix:DR
First Name:KASSIM
Middle Name:A
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1001 12TH AVE
Mailing Address - Street 2:SUITE 132
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3926
Mailing Address - Country:US
Mailing Address - Phone:817-870-2010
Mailing Address - Fax:817-870-2050
Practice Address - Street 1:1001 12TH AVE
Practice Address - Street 2:SUITE 132
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3926
Practice Address - Country:US
Practice Address - Phone:817-870-2010
Practice Address - Fax:817-870-2050
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXH7171207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXC57180Medicare UPIN
TX8C5879Medicare PIN
TXP00206473Medicare PIN
TX8C9478Medicare PIN