Provider Demographics
NPI:1508846452
Name:KHAN, FARHAT A (MD)
Entity Type:Individual
Prefix:
First Name:FARHAT
Middle Name:A
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 1:620 W BROWN ST
Mailing Address - Street 2:
Mailing Address - City:WAUPUN
Mailing Address - State:WI
Mailing Address - Zip Code:53963-1702
Mailing Address - Country:US
Mailing Address - Phone:920-324-6522
Mailing Address - Fax:
Practice Address - Street 1:620 W BROWN ST
Practice Address - Street 2:
Practice Address - City:WAUPUN
Practice Address - State:WI
Practice Address - Zip Code:53963-1702
Practice Address - Country:US
Practice Address - Phone:920-324-6522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2021-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI40765208M00000X
WI40764207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIH03956Medicare UPIN