Provider Demographics
NPI:1962815852
Name:KHAN, MARIUM (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIUM
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 1:4500 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2515
Mailing Address - Country:US
Mailing Address - Phone:228-575-1194
Mailing Address - Fax:228-575-2917
Practice Address - Street 1:4333 15TH ST STE A
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2525
Practice Address - Country:US
Practice Address - Phone:228-863-4000
Practice Address - Fax:228-863-4003
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-09
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2897171207R00000X
MS28681207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine