Provider Demographics
NPI:1811557556
Name:KHAN, FARYAL (MD)
Entity Type:Individual
Prefix:
First Name:FARYAL
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 1:3910 LIMA RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1031
Mailing Address - Country:US
Mailing Address - Phone:260-420-6010
Mailing Address - Fax:
Practice Address - Street 1:3910 LIMA RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1031
Practice Address - Country:US
Practice Address - Phone:260-420-6010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01091378A207QA0401X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine