Provider Demographics
NPI:1659567089
Name:SHAHJEHAN, KHURRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:KHURRAM
Middle Name:
Last Name:SHAHJEHAN
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 1:1600 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3019
Mailing Address - Country:US
Mailing Address - Phone:863-680-7000
Mailing Address - Fax:866-264-8519
Practice Address - Street 1:1600 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3019
Practice Address - Country:US
Practice Address - Phone:863-680-7000
Practice Address - Fax:866-264-8519
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01067487207RC0200X
IL36117952207R00000X
FLME133811207RP1001X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022350200Medicaid
IN200986020Medicaid
INP00895110OtherR.R. MEDICARE
IN000000669014OtherANTHEM
MNENROLLEDMedicaid
MN810000238Medicare PIN
INM400023748Medicare PIN