Provider Demographics
NPI:1679540298
Name:KHATTAK, TASLIM A (MD)
Entity Type:Individual
Prefix:
First Name:TASLIM
Middle Name:A
Last Name:KHATTAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6005 PARK AVE STE 433B
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5211
Mailing Address - Country:US
Mailing Address - Phone:901-255-1140
Mailing Address - Fax:901-255-1143
Practice Address - Street 1:6005 PARK AVE STE 433B
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-5211
Practice Address - Country:US
Practice Address - Phone:901-255-1140
Practice Address - Fax:901-255-1143
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD29699207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3724095Medicaid
MS00121275Medicaid
MS09016225Medicaid
TN3821006Medicaid
TN3144565OtherBCBST
MS09016225Medicaid
TN3724095Medicaid
MS00121275Medicaid