Provider Demographics
NPI:1891834685
Name:KHAN, FAZAL AB (MD)
Entity Type:Individual
Prefix:
First Name:FAZAL
Middle Name:AB
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 1:6416 OLD WINTER GARDEN RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-1348
Mailing Address - Country:US
Mailing Address - Phone:407-447-7121
Mailing Address - Fax:407-770-0661
Practice Address - Street 1:5568 WESLAYAN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77005-1942
Practice Address - Country:US
Practice Address - Phone:713-666-7050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-117596207Q00000X
TXN2592207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BZ702OtherBCBS
TX201606501Medicaid
TX8L12212Medicare PIN