Provider Demographics
NPI:1710168729
Name:KASSIM A KHAN MD PA
Entity Type:Organization
Organization Name:KASSIM A KHAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KASSIM
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:817-870-2010
Mailing Address - Street 1:1001 12TH AVE
Mailing Address - Street 2:SUITE 132
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-3926
Mailing Address - Country:US
Mailing Address - Phone:817-870-2010
Mailing Address - Fax:817-870-2050
Practice Address - Street 1:1001 12TH AVE
Practice Address - Street 2:SUITE 132
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-3926
Practice Address - Country:US
Practice Address - Phone:817-870-2010
Practice Address - Fax:817-870-2050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2009-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7171207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00339XMedicare PIN
TX00753XMedicare PIN
TXDD0645Medicare PIN