Provider Demographics
NPI:1669430567
Name:KHAN, FAZAL (MD)
Entity type:Individual
Prefix:DR
First Name:FAZAL
Middle Name:
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 1:13707 W JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-3188
Mailing Address - Country:US
Mailing Address - Phone:815-337-1871
Mailing Address - Fax:815-338-6297
Practice Address - Street 1:10350 HALIGUS RD
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-9558
Practice Address - Country:US
Practice Address - Phone:815-338-6600
Practice Address - Fax:847-802-7203
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036104590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL080195055OtherMEDICARE RAILROAD
IL962341Medicare PIN