Provider Demographics
NPI:1629431374
Name:KHAN, TAHIR
Entity Type:Individual
Prefix:
First Name:TAHIR
Middle Name:
Last Name:KHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15010 CORDELL AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22193-1914
Mailing Address - Country:US
Mailing Address - Phone:571-315-1022
Mailing Address - Fax:
Practice Address - Street 1:37595 SEVEN MILE ROAD
Practice Address - Street 2:SUITE 340
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152
Practice Address - Country:US
Practice Address - Phone:734-793-2471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH35.136408208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program