Provider Demographics
NPI:1578520730
Name:KHATTAK, ASIM J (MD)
Entity Type:Individual
Prefix:DR
First Name:ASIM
Middle Name:J
Last Name:KHATTAK
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 1:1578 W ORANGE BLOSSOM TRL BLDG 1560
Mailing Address - Street 2:
Mailing Address - City:APOPKA
Mailing Address - State:FL
Mailing Address - Zip Code:32712-2639
Mailing Address - Country:US
Mailing Address - Phone:407-635-3027
Mailing Address - Fax:321-203-4649
Practice Address - Street 1:1578 W ORANGE BLOSSOM TRL BLDG 1560
Practice Address - Street 2:
Practice Address - City:APOPKA
Practice Address - State:FL
Practice Address - Zip Code:32712-2639
Practice Address - Country:US
Practice Address - Phone:407-635-3027
Practice Address - Fax:321-203-4649
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2020-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84397207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265381800Medicaid
FLH64836Medicare UPIN