Provider Demographics
NPI:1265419683
Name:KHATTAK, HAFIZ (MD)
Entity type:Individual
Prefix:
First Name:HAFIZ
Middle Name:
Last Name:KHATTAK
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 2153 DEPT 30703
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35287-9256
Mailing Address - Country:US
Mailing Address - Phone:314-961-3038
Mailing Address - Fax:314-961-6731
Practice Address - Street 1:7491 BIG BEND BLVD
Practice Address - Street 2:
Practice Address - City:WEBSTER GROVES
Practice Address - State:MO
Practice Address - Zip Code:63119-2101
Practice Address - Country:US
Practice Address - Phone:314-961-3038
Practice Address - Fax:618-398-6266
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-28
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000161127208100000X, 208VP0000X
IL036101887208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO205739006Medicaid
MO205739006Medicaid
MO002013516Medicare ID - Type Unspecified