Provider Demographics
NPI:1720031677
Name:DANSVILLE INTERNAL MEDICINE ASSOC PC
Entity Type:Organization
Organization Name:DANSVILLE INTERNAL MEDICINE ASSOC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALAYAT
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-335-8320
Mailing Address - Street 1:790 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2716
Mailing Address - Country:US
Mailing Address - Phone:585-385-9030
Mailing Address - Fax:585-385-9124
Practice Address - Street 1:92 MAIN ST
Practice Address - Street 2:
Practice Address - City:DANSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14437-1609
Practice Address - Country:US
Practice Address - Phone:585-335-8320
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115189207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY16679AMedicare PIN