Provider Demographics
NPI:1497794135
Name:KHAN, JEREMY S (MD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:S
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 1:759 PEACHTREE PKWY
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-9350
Mailing Address - Country:US
Mailing Address - Phone:404-804-0024
Mailing Address - Fax:470-237-2457
Practice Address - Street 1:759 PEACHTREE PKWY
Practice Address - Street 2:SUITE 3
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-9350
Practice Address - Country:US
Practice Address - Phone:404-804-0024
Practice Address - Fax:470-237-2457
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2014-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA054439207RC0000X
GAGA054439207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA608617837AMedicaid