Provider Demographics
NPI:1629162359
Name:KHAN, WAJID A (MD)
Entity Type:Individual
Prefix:DR
First Name:WAJID
Middle Name:A
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 1:185 PENNY AVE
Mailing Address - Street 2:
Mailing Address - City:EAST DUNDEE
Mailing Address - State:IL
Mailing Address - Zip Code:60118-1454
Mailing Address - Country:US
Mailing Address - Phone:847-836-7015
Mailing Address - Fax:
Practice Address - Street 1:200 N HAMMES AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6677
Practice Address - Country:US
Practice Address - Phone:815-744-8253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361150382084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036115038Medicaid
IL0991516762OtherBCBS
IL0991516762OtherBCBS
ILI50680Medicare UPIN
ILK26257Medicare ID - Type UnspecifiedCOOK COUNTY
ILIL5311001Medicare PIN
ILK26256Medicare ID - Type UnspecifiedDUPAGE COUNTY