Provider Demographics
NPI:1689632036
Name:KHAN, SHAHZAD A (MD)
Entity Type:Individual
Prefix:
First Name:SHAHZAD
Middle Name:A
Last Name:KHAN
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 1:525 IRON STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:LEHIGHTON
Mailing Address - State:PA
Mailing Address - Zip Code:18235-1949
Mailing Address - Country:US
Mailing Address - Phone:610-379-4677
Mailing Address - Fax:610-379-4678
Practice Address - Street 1:525 IRON STREET
Practice Address - Street 2:SUITE B
Practice Address - City:LEHIGHTON
Practice Address - State:PA
Practice Address - Zip Code:18235-1949
Practice Address - Country:US
Practice Address - Phone:610-379-4677
Practice Address - Fax:610-379-4678
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMD1114042084N0400X
PAMD-4316492084N0600X, 2084S0012X
PAMD4316492084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO130018287OtherRR MEDICARE
MO209784305Medicaid
PA102004244-001OtherMEDIAL ASSISTANT
PA102004244-001OtherMEDIAL ASSISTANT
MO209784305Medicaid
G71469Medicare UPIN
G71469Medicare UPIN