Provider Demographics
NPI:1417138157
Name:SHUJAAT A KHAN M D P A
Entity Type:Organization
Organization Name:SHUJAAT A KHAN M D P A
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHUJAAT
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-335-6363
Mailing Address - Street 1:800 8TH AVE
Mailing Address - Street 2:STE 404
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-335-6363
Mailing Address - Fax:817-870-1222
Practice Address - Street 1:800 8TH AVE
Practice Address - Street 2:STE 404
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-335-6363
Practice Address - Fax:817-870-1222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-23
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE51322086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX86W281OtherBCBS
TX200N93TMedicaid
TX4119241OtherAETNA
TX00N93TMedicare PIN
TXC17844Medicare UPIN