Provider Demographics
NPI:1417046038
Name:KHAN, MOID (MD)
Entity Type:Individual
Prefix:
First Name:MOID
Middle Name:
Last Name:KHAN
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 1:531 WASHINGTON ST
Mailing Address - Street 2:STE 2401
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4069
Mailing Address - Country:US
Mailing Address - Phone:315-788-3070
Mailing Address - Fax:315-788-8061
Practice Address - Street 1:531 WASHINGTON ST
Practice Address - Street 2:STE 2401
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4069
Practice Address - Country:US
Practice Address - Phone:315-788-3070
Practice Address - Fax:315-788-8061
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2020-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY130228207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY39485BMedicare PIN
NYD78443Medicare UPIN