Provider Demographics
NPI:1629065404
Name:KHAN, AHMAD ZIA (MD)
Entity Type:Individual
Prefix:
First Name:AHMAD
Middle Name:ZIA
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 1:8700 DURAND AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-2096
Mailing Address - Country:US
Mailing Address - Phone:262-635-5520
Mailing Address - Fax:262-635-5530
Practice Address - Street 1:8700 DURAND AVE STE 600
Practice Address - Street 2:
Practice Address - City:STURTEVANT
Practice Address - State:WI
Practice Address - Zip Code:53177-2096
Practice Address - Country:US
Practice Address - Phone:262-635-5520
Practice Address - Fax:262-635-5530
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41158-0202084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32554100Medicaid
WI32554100Medicaid
WI001552430Medicare ID - Type Unspecified