Provider Demographics
NPI:1942229810
Name:KHAN, NAEEM ANWAR (MD)
Entity Type:Individual
Prefix:
First Name:NAEEM
Middle Name:ANWAR
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:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:IL
Mailing Address - Zip Code:62801
Mailing Address - Country:US
Mailing Address - Phone:618-532-8574
Mailing Address - Fax:618-532-0801
Practice Address - Street 1:1050 MARTIN LUTHER KING DRIVE
Practice Address - Street 2:STE #108
Practice Address - City:CENTRALIA
Practice Address - State:IL
Practice Address - Zip Code:62801
Practice Address - Country:US
Practice Address - Phone:618-532-8574
Practice Address - Fax:618-532-0801
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR3K03207RC0000X
IL207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
D14875Medicare UPIN
K20397Medicare ID - Type Unspecified