Provider Demographics
NPI:1578697348
Name:KHAN, GULAM QUTUBUDDIN (MD)
Entity Type:Individual
Prefix:
First Name:GULAM
Middle Name:QUTUBUDDIN
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 1:740 S LIMESTONE
Mailing Address - Street 2:J 401
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-4012
Mailing Address - Country:US
Mailing Address - Phone:859-323-5661
Mailing Address - Fax:859-257-4999
Practice Address - Street 1:740 S LIMESTONE
Practice Address - Street 2:J 401
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-4012
Practice Address - Country:US
Practice Address - Phone:859-323-5661
Practice Address - Fax:859-257-4999
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY407012084N0400X, 2084N0402X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00258056Medicare PIN