Provider Demographics
NPI:1417999335
Name:KHAN, EHTISHAM R (MD)
Entity Type:Individual
Prefix:DR
First Name:EHTISHAM
Middle Name:R
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:PO BOX 2705
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-2705
Mailing Address - Country:US
Mailing Address - Phone:256-265-5970
Mailing Address - Fax:256-817-5969
Practice Address - Street 1:8371 HIGHWAY 72 W
Practice Address - Street 2:SUITE 104
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758-9505
Practice Address - Country:US
Practice Address - Phone:256-265-5970
Practice Address - Fax:256-817-5956
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00019019207P00000X
AL19019207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009932196Medicaid
AL109211Medicaid
AL515-96535OtherBLUE CROSS OF ALABAMA
AL102I117075Medicare PIN
AL051525976KHAMedicare ID - Type Unspecified
G22640Medicare UPIN