Provider Demographics
NPI:1417183435
Name:KHAN, FAWAD J (MD)
Entity Type:Individual
Prefix:
First Name:FAWAD
Middle Name:J
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 1:100 E CARROLL ST
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:MD
Mailing Address - Zip Code:21801-5422
Mailing Address - Country:US
Mailing Address - Phone:800-749-5191
Mailing Address - Fax:410-630-7685
Practice Address - Street 1:100 E CARROLL ST
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:MD
Practice Address - Zip Code:21801
Practice Address - Country:US
Practice Address - Phone:800-749-5191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV235872086S0102X
MDD00857392086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810016927Medicaid
WV3810016927Medicaid