Provider Demographics
NPI:1255533881
Name:KHAN, TARA (DO)
Entity type:Individual
Prefix:DR
First Name:TARA
Middle Name:
Last Name:KHAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12479 TELECOM DRIVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33637-0913
Mailing Address - Country:US
Mailing Address - Phone:813-972-4199
Mailing Address - Fax:813-972-5753
Practice Address - Street 1:3100 E FLETCHER AVENUE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-4613
Practice Address - Country:US
Practice Address - Phone:813-971-6000
Practice Address - Fax:813-972-5753
Is Sole Proprietor?:No
Enumeration Date:2007-06-05
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238186-1207P00000X
FLOS10823207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02957922Medicaid
FL001717300Medicaid
FLCR425VMedicare PIN
NYJ400008745Medicare PIN