Provider Demographics
NPI:1720212715
Name:KHAN, ALISA (MD)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:
Last Name:KHAN
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 1:303 THIRD ST
Mailing Address - Street 2:#615
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02142-1156
Mailing Address - Country:US
Mailing Address - Phone:410-736-3399
Mailing Address - Fax:
Practice Address - Street 1:300 LONGWOOD AVE, AU-521, CHILDREN'S HOSPITAL BOSTON
Practice Address - Street 2:HARVARD PEDIATRIC HEALTH SERVICES RESEARCH FELLOWSHIP
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-8298
Practice Address - Fax:617-730-0174
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA250817208000000X
MD390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program