Provider Demographics
NPI:1922002906
Name:KHAN, TARIQ MAHMOOD (MD)
Entity Type:Individual
Prefix:
First Name:TARIQ
Middle Name:MAHMOOD
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 1:1684 FOOTE AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-9385
Mailing Address - Country:US
Mailing Address - Phone:716-661-9730
Mailing Address - Fax:716-661-9732
Practice Address - Street 1:1684 FOOTE AVENUE EXT
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-9385
Practice Address - Country:US
Practice Address - Phone:716-661-9730
Practice Address - Fax:716-661-9732
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207469-1208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02366347Medicaid
NY1290375OtherINDEPENDENT HEALTH ID
NY00021051301OtherUNIVERA/EXCELLUS
NY00021051301OtherRMSCO ID
NY01664951Medicaid
NY72679OtherTHE CHAUTAUQUA PLAN IDS
NY040426036267OtherFIDELISCARE NEW YORK ID
NY161570481OtherFEDERAL TAX ID (COMM INS)
NY000524287002OtherBLUECROSS BLUESHIELD WNY