Provider Demographics
NPI:1700506201
Name:KHAN, QASIM SARDAR (MD)
Entity Type:Individual
Prefix:DR
First Name:QASIM
Middle Name:SARDAR
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 1:600 N GRATTON AVE
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-4313
Mailing Address - Country:US
Mailing Address - Phone:336-259-9181
Mailing Address - Fax:
Practice Address - Street 1:13013 FULLER AVE STE A
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-2687
Practice Address - Country:US
Practice Address - Phone:816-214-5548
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-02
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022026954207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine