Provider Demographics
NPI:1669648309
Name:KHATTAK, MUHAMMAD WAQAR (MD)
Entity Type:Individual
Prefix:
First Name:MUHAMMAD
Middle Name:WAQAR
Last Name:KHATTAK
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 1:420 NE GLEN OAK AVE
Mailing Address - Street 2:STE 401
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61603-3168
Mailing Address - Country:US
Mailing Address - Phone:309-676-8123
Mailing Address - Fax:309-676-8455
Practice Address - Street 1:420 NE GLEN OAK AVE STE 401
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603
Practice Address - Country:US
Practice Address - Phone:309-676-8123
Practice Address - Fax:309-676-8455
Is Sole Proprietor?:No
Enumeration Date:2008-05-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-139349207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036139349Medicaid
MA000626701Medicare PIN