Provider Demographics
NPI:1013971852
Name:HUSAIN, KHURSHID (MD)
Entity Type:Individual
Prefix:
First Name:KHURSHID
Middle Name:
Last Name:HUSAIN
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 588
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43301-0588
Mailing Address - Country:US
Mailing Address - Phone:740-361-5868
Mailing Address - Fax:740-914-4550
Practice Address - Street 1:1245 FOREST HILL DR
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6529
Practice Address - Country:US
Practice Address - Phone:740-361-5868
Practice Address - Fax:740-914-4550
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-17
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35039678H207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
311098079123OtherCIGNA
0100697OtherUHC
353077OtherEDI SUBMITTER NO
OH311098079OtherPPONEXT
634564OtherAETNA
OH000000118384OtherANTHEMBCBS
OH0328130Medicaid
634564OtherAETNA
OH0328130Medicaid
0100697OtherUHC
311098079OtherTIN