Provider Demographics
NPI:1295925253
Name:KHAN, TARIQ A (MD)
Entity type:Individual
Prefix:DR
First Name:TARIQ
Middle Name:A
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 1:14642 NEWPORT AVE
Mailing Address - Street 2:SUITE 408
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6091
Mailing Address - Country:US
Mailing Address - Phone:657-218-9859
Mailing Address - Fax:657-218-4023
Practice Address - Street 1:14642 NEWPORT AVE
Practice Address - Street 2:SUITE 408
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6091
Practice Address - Country:US
Practice Address - Phone:657-218-9859
Practice Address - Fax:657-218-4023
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA112661207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB252639Medicare UPIN