Provider Demographics
NPI:1235545534
Name:DAHA, FARAZ AHMAD KHAN (MD)
Entity Type:Individual
Prefix:
First Name:FARAZ AHMAD KHAN
Middle Name:
Last Name:DAHA
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 1:6815 118TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53142-8420
Mailing Address - Country:US
Mailing Address - Phone:262-857-5600
Mailing Address - Fax:
Practice Address - Street 1:6815 118TH AVE
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-8420
Practice Address - Country:US
Practice Address - Phone:262-857-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301116619207L00000X
WI2896208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100241342Medicaid