Provider Demographics
NPI:1649336546
Name:KHAN, AGHA BABER
Entity type:Individual
Prefix:
First Name:AGHA
Middle Name:BABER
Last Name:KHAN
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:AGHA
Other - Middle Name:BABER
Other - Last Name:KHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 8090
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008-8090
Mailing Address - Country:US
Mailing Address - Phone:719-544-0052
Mailing Address - Fax:719-545-1590
Practice Address - Street 1:1303 FORTINO BLVD STE A
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008-2032
Practice Address - Country:US
Practice Address - Phone:719-544-0052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR37853207RE0101X
AZ28422207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO70773874Medicaid