Provider Demographics
NPI:1184603755
Name:KHAN, FAWAD (MD)
Entity type:Individual
Prefix:
First Name:FAWAD
Middle Name:
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 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:800-326-2250
Mailing Address - Fax:
Practice Address - Street 1:600 WALNUT RIDGE DR
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:WI
Practice Address - Zip Code:53029-9385
Practice Address - Country:US
Practice Address - Phone:262-369-7040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38768207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32334800Medicaid
WIG52310Medicare UPIN
WI32334800Medicaid