Provider Demographics
NPI:1679650378
Name:KHAN, TASNEEM AHMAD (MD)
Entity Type:Individual
Prefix:
First Name:TASNEEM
Middle Name:AHMAD
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1635 CENTRAL AVENUE
Mailing Address - Street 2:ROOM 213 SOUTHWEST CT MENTAL HEALTH SYSTEM
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610
Mailing Address - Country:US
Mailing Address - Phone:203-551-7660
Mailing Address - Fax:203-551-7481
Practice Address - Street 1:1635 CENTRAL AVENUE
Practice Address - Street 2:ROOM 213 SOUTHWEST CT MENTAL HEALTH SYSTEM
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610
Practice Address - Country:US
Practice Address - Phone:203-551-7660
Practice Address - Fax:203-551-7481
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT0340052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
G59300Medicare UPIN