Provider Demographics
NPI:1124322417
Name:KHAN, ULFAT SANAM
Entity type:Individual
Prefix:DR
First Name:ULFAT
Middle Name:SANAM
Last Name:KHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 N 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-2403
Mailing Address - Country:US
Mailing Address - Phone:708-369-7835
Mailing Address - Fax:
Practice Address - Street 1:704 E RAND RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-4006
Practice Address - Country:US
Practice Address - Phone:847-259-3933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-01
Last Update Date:2016-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-010414152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL579250130Medicare PIN