Provider Demographics
NPI:1467481085
Name:KHAN, IMTIAZ A (DO)
Entity type:Individual
Prefix:DR
First Name:IMTIAZ
Middle Name:A
Last Name:KHAN
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:4416 FOREST DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-3104
Mailing Address - Country:US
Mailing Address - Phone:803-782-4278
Mailing Address - Fax:803-782-3445
Practice Address - Street 1:4200 E NORTH ST
Practice Address - Street 2:SUITE 5
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-2437
Practice Address - Country:US
Practice Address - Phone:864-292-2266
Practice Address - Fax:864-292-8356
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
SC492207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G96104Medicare UPIN