Provider Demographics
NPI:1558433599
Name:KHANAM, LUTFA (MD)
Entity Type:Individual
Prefix:
First Name:LUTFA
Middle Name:
Last Name:KHANAM
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 1:1855 MOTT AVE
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-4201
Mailing Address - Country:US
Mailing Address - Phone:718-868-8282
Mailing Address - Fax:718-471-2865
Practice Address - Street 1:1855 MOTT AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4201
Practice Address - Country:US
Practice Address - Phone:718-868-8282
Practice Address - Fax:718-471-2865
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200170208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01797891Medicaid