Provider Demographics
NPI:1780675439
Name:KHAN, ABDUR R (MD)
Entity Type:Individual
Prefix:
First Name:ABDUR
Middle Name:R
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:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2901 W KINNICKINNIC RIVER PKWY
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3677
Practice Address - Country:US
Practice Address - Phone:414-646-8990
Practice Address - Fax:414-646-8995
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35089520207R00000X
WV21760207R00000X
WI69966207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100081242Medicaid
WV3810002265Medicaid
OH2767840Medicaid
OHKH7390681Medicare PIN
WVI24402Medicare UPIN
OH2767840Medicaid
OHH104120Medicare PIN