Provider Demographics
NPI:1700803624
Name:PRIMARY CARE CENTER OF LYNN HAVEN
Entity Type:Organization
Organization Name:PRIMARY CARE CENTER OF LYNN HAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ASIM
Authorized Official - Middle Name:J
Authorized Official - Last Name:KHATTAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:850-265-3686
Mailing Address - Street 1:PO BOX 1199
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-1199
Mailing Address - Country:US
Mailing Address - Phone:850-265-3686
Mailing Address - Fax:850-271-5665
Practice Address - Street 1:825 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LYNN HAVEN
Practice Address - State:FL
Practice Address - Zip Code:32444-2335
Practice Address - Country:US
Practice Address - Phone:850-265-3686
Practice Address - Fax:850-271-5665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-16
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1700803624OtherNPI
FL276096700Medicaid
FL276096700Medicaid