Provider Demographics
NPI:1538140884
Name:KHAN, ADIL A (MD)
Entity Type:Individual
Prefix:
First Name:ADIL
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 1:1251 W KEM ROAD
Mailing Address - Street 2:SUITE E
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2555
Mailing Address - Country:US
Mailing Address - Phone:765-662-4133
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:1000 E MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0027
Practice Address - Country:US
Practice Address - Phone:570-808-6026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-11
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048805A2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000200028OtherANTHEM BCBS
IN200316350AMedicaid
IN200316350AMedicaid
IN296260BBMedicare PIN
IN296030BMedicare ID - Type Unspecified