Provider Demographics
NPI:1295944163
Name:KHAN, ABDUL SAMI (MD)
Entity type:Individual
Prefix:
First Name:ABDUL
Middle Name:SAMI
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:FROEDTERT SOUTH
Mailing Address - Street 2:6308 8TH AVENUE
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143
Mailing Address - Country:US
Mailing Address - Phone:262-577-8522
Mailing Address - Fax:262-653-5850
Practice Address - Street 1:9697 SAINT CATHERINES DR
Practice Address - Street 2:
Practice Address - City:PLEASANT PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53158-2118
Practice Address - Country:US
Practice Address - Phone:262-653-5330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073420A207R00000X
IL036117736207RG0100X
WI65380-20207RG0100X
WI65380207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1295944163Medicaid
LA4N2547061OtherMEDICARE
LA1176508Medicaid
ABIM-MOCOtherAMERICAN BOARD OF INTERNAL MEDICINE
IN201203720Medicaid
IN201203720Medicaid
LA4N2547061OtherMEDICARE
WI1295944163Medicaid