Provider Demographics
NPI:1518967587
Name:KHAN, AMTULLAH (MD)
Entity Type:Individual
Prefix:
First Name:AMTULLAH
Middle Name:
Last Name:KHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 TRADEPARK DR
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3424
Mailing Address - Country:US
Mailing Address - Phone:606-451-3755
Mailing Address - Fax:606-451-3576
Practice Address - Street 1:112 TRADEPARK DR
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3424
Practice Address - Country:US
Practice Address - Phone:606-451-3755
Practice Address - Fax:606-451-3576
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY276222085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000220075OtherANTHEM PIN
KY2400015OtherUNITED HEALTHCARE PIN
KY64276223Medicaid
KY043623469OtherHUMANA PIN
KY043623469OtherCHA PIN
KY043623469OtherHUMANA PIN
KY64276223Medicaid