Provider Demographics
NPI:1467754192
Name:HUMAIRA KHAN MD PA
Entity Type:Organization
Organization Name:HUMAIRA KHAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HUMAIRA
Authorized Official - Middle Name:V
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-486-8663
Mailing Address - Street 1:PO BOX 100488
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33310-0488
Mailing Address - Country:US
Mailing Address - Phone:954-486-8663
Mailing Address - Fax:954-486-8979
Practice Address - Street 1:4850 W OAKLAND PARK BLVD
Practice Address - Street 2:#132
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33313-7260
Practice Address - Country:US
Practice Address - Phone:954-486-8663
Practice Address - Fax:954-486-8979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81096207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261038800Medicaid
FLF82963Medicare UPIN
FL261038800Medicaid