Provider Demographics
NPI:1740430545
Name:KHAN, MOAZZEM HOSSAIN (MD)
Entity Type:Individual
Prefix:
First Name:MOAZZEM
Middle Name:HOSSAIN
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:HAVILAND HALL
Mailing Address - Street 2:12 JOYCE DRIVE
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-1886
Mailing Address - Country:US
Mailing Address - Phone:347-446-9114
Mailing Address - Fax:860-262-6525
Practice Address - Street 1:HAVILAND HALL
Practice Address - Street 2:12 JOYCE DRIVE
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-6407
Practice Address - Country:US
Practice Address - Phone:860-262-7026
Practice Address - Fax:860-262-6525
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT67320207R00000X
AK4933207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine