Provider Demographics
NPI:1497794507
Name:KHAN, AYAZ (OD)
Entity Type:Individual
Prefix:DR
First Name:AYAZ
Middle Name:
Last Name:KHAN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 AUTO CLUB DR
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2779
Mailing Address - Country:US
Mailing Address - Phone:313-359-8777
Mailing Address - Fax:
Practice Address - Street 1:5500 AUTO CLUB DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126
Practice Address - Country:US
Practice Address - Phone:313-359-8777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003725152W00000X
IL046010193152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL6476980001Medicare NSC
ILIL3505001Medicare PIN