Provider Demographics
NPI:1518675933
Name:KHAN, ISHTIAQUE A
Entity Type:Individual
Prefix:
First Name:ISHTIAQUE
Middle Name:A
Last Name:KHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6136 170TH ST APT M4
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-1957
Mailing Address - Country:US
Mailing Address - Phone:516-794-7200
Mailing Address - Fax:516-441-6768
Practice Address - Street 1:6136 170TH ST APT M4
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-1957
Practice Address - Country:US
Practice Address - Phone:718-709-0940
Practice Address - Fax:516-441-6768
Is Sole Proprietor?:No
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP117921207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine