Provider Demographics
NPI:1740545441
Name:KHATTAK, MARIA (MD)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:KHATTAK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 S MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-4030
Mailing Address - Country:US
Mailing Address - Phone:217-789-1403
Mailing Address - Fax:217-789-1825
Practice Address - Street 1:1836 S MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4030
Practice Address - Country:US
Practice Address - Phone:217-789-1403
Practice Address - Fax:217-789-1825
Is Sole Proprietor?:No
Enumeration Date:2012-07-09
Last Update Date:2015-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036136594207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine