Provider Demographics
NPI:1366639221
Name:KHAN, SYEDA MAIMUNA ALI (MD)
Entity Type:Individual
Prefix:
First Name:SYEDA
Middle Name:MAIMUNA ALI
Last Name:KHAN
Suffix:
Gender:F
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:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-7770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12901 BRUCE B DOWNS BLVD
Practice Address - Street 2:MDC19
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-4742
Practice Address - Country:US
Practice Address - Phone:813-974-2201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY245634207R00000X, 208M00000X
GA86127207R00000X
FLME107445207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14A4DOtherBLUE CROSS BLUE SHIELD
FL002800300Medicaid
FLDZ350ZMedicare PIN
FL002800300Medicaid