Provider Demographics
NPI:1366482374
Name:KHAN, NASIRUDDIN ALI (OD)
Entity Type:Individual
Prefix:
First Name:NASIRUDDIN
Middle Name:ALI
Last Name:KHAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93291-4331
Mailing Address - Country:US
Mailing Address - Phone:559-636-1000
Mailing Address - Fax:559-733-7438
Practice Address - Street 1:431 N IRWIN ST
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-4425
Practice Address - Country:US
Practice Address - Phone:559-582-9244
Practice Address - Fax:559-582-2748
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT 12386 TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT 12386 TPAOtherOPTOMOTRY LICENSE
CAOPT 12386 TPAOtherOPTOMOTRY LICENSE
CAU96537Medicare UPIN