Provider Demographics
NPI:1376910398
Name:KHAN, DURDANA
Entity Type:Individual
Prefix:
First Name:DURDANA
Middle Name:
Last Name:KHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 W MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11580-4521
Mailing Address - Country:US
Mailing Address - Phone:917-535-7609
Mailing Address - Fax:631-991-3386
Practice Address - Street 1:672 WELLWOOD AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-1677
Practice Address - Country:US
Practice Address - Phone:631-225-2623
Practice Address - Fax:631-991-3386
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-25
Last Update Date:2015-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
NY27 026389174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist