Provider Demographics
NPI:1821397100
Name:KHAN, TAZLEEM SHAZAD (MD)
Entity Type:Individual
Prefix:
First Name:TAZLEEM
Middle Name:SHAZAD
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:155 CRYSTAL RUN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-4028
Mailing Address - Country:US
Mailing Address - Phone:845-703-6999
Mailing Address - Fax:845-703-6297
Practice Address - Street 1:4250 HEMPSTEAD TPKE STE 17
Practice Address - Street 2:
Practice Address - City:BETHPAGE
Practice Address - State:NY
Practice Address - Zip Code:11714-5707
Practice Address - Country:US
Practice Address - Phone:516-735-5522
Practice Address - Fax:516-644-5385
Is Sole Proprietor?:No
Enumeration Date:2011-03-25
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276217207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400150290Medicare PIN