Provider Demographics
NPI:1336273119
Name:KHAN, JAWAD (MD)
Entity Type:Individual
Prefix:
First Name:JAWAD
Middle Name:
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8601 WEST MAIN STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62223
Mailing Address - Country:US
Mailing Address - Phone:618-398-6266
Mailing Address - Fax:618-398-6293
Practice Address - Street 1:8601 WEST MAIN STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62223
Practice Address - Country:US
Practice Address - Phone:618-398-6266
Practice Address - Fax:618-398-6293
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036103822207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH41009Medicare UPIN