Provider Demographics
NPI:1790996288
Name:DASTAGIR A KHAN MD PA
Entity Type:Organization
Organization Name:DASTAGIR A KHAN MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DASTAGIR
Authorized Official - Middle Name:A
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-955-7190
Mailing Address - Street 1:207 BARONY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-6119
Mailing Address - Country:US
Mailing Address - Phone:904-955-7190
Mailing Address - Fax:
Practice Address - Street 1:800 PRUDENTIAL DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8202
Practice Address - Country:US
Practice Address - Phone:904-955-7190
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME82073207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270290800Medicaid
FL57641OtherBCBS OF FLORIDA
FLD06811OtherRAILROAD MEDICARE
FL270290800Medicaid