Provider Demographics
NPI:1427021948
Name:KHAN, FAROUK (MD, PHD)
Entity Type:Individual
Prefix:
First Name:FAROUK
Middle Name:
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2812 HARTFORD HWY STE 1
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-4927
Mailing Address - Country:US
Mailing Address - Phone:334-712-1170
Mailing Address - Fax:
Practice Address - Street 1:25 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-3801
Practice Address - Country:US
Practice Address - Phone:815-599-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361056842084N0400X
AL213222084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036105684Medicaid
AL147462Medicaid
AL197881Medicaid
ILG68984Medicare UPIN