Provider Demographics
NPI:1538697248
Name:KHAN, MIRZA ALI U (DO)
Entity Type:Individual
Prefix:
First Name:MIRZA ALI
Middle Name:U
Last Name:KHAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1423 ASHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-8885
Mailing Address - Country:US
Mailing Address - Phone:847-528-3366
Mailing Address - Fax:
Practice Address - Street 1:1954 GATEWAY CENTER DR
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-9303
Practice Address - Country:US
Practice Address - Phone:815-544-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-24
Last Update Date:2020-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.152072207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine