Provider Demographics
NPI:1568677961
Name:KHANI, FRED D (DO)
Entity Type:Individual
Prefix:DR
First Name:FRED
Middle Name:D
Last Name:KHANI
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:FERAYDOON
Other - Middle Name:
Other - Last Name:KHANI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:2140 NE 26TH ST
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305-1536
Mailing Address - Country:US
Mailing Address - Phone:954-566-7433
Mailing Address - Fax:954-963-2380
Practice Address - Street 1:2140 NE 26TH ST
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305-1536
Practice Address - Country:US
Practice Address - Phone:954-566-7433
Practice Address - Fax:954-963-2380
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS1502207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOS1502OtherLICENSE