Provider Demographics
NPI:1619946159
Name:KHAN, KHUDA DAD (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:KHUDA
Middle Name:DAD
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776347
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6347
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:315 E BROADWAY FL 4
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202
Practice Address - Country:US
Practice Address - Phone:502-629-2500
Practice Address - Fax:502-629-2055
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY41517207RH0003X
IN01052174A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200282440Medicaid
KY7100056260Medicaid
KYP01190187OtherMEDICARE RAILROAD
AZ631888Medicaid
AZ631888Medicaid
IN256630BMedicare PIN
IN200282440Medicaid
KYK054650Medicare Oscar/Certification
P00199498Medicare PIN
IN224290EMedicare PIN