Provider Demographics
NPI:1356481261
Name:KHAN, IMTIAZ AHMAD (MD)
Entity type:Individual
Prefix:DR
First Name:IMTIAZ
Middle Name:AHMAD
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 1:908 ADAIR AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-3806
Mailing Address - Country:US
Mailing Address - Phone:404-733-6554
Mailing Address - Fax:678-442-4416
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-7694
Practice Address - Country:US
Practice Address - Phone:678-442-3317
Practice Address - Fax:678-442-4416
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA035077207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00538964DMedicaid
GA93BDKPHMedicare ID - Type Unspecified
GA00538964DMedicaid