Provider Demographics
NPI:1750373189
Name:KHAN, SHAGUFTA (MD)
Entity type:Individual
Prefix:
First Name:SHAGUFTA
Middle Name:
Last Name:KHAN
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:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:
Practice Address - Street 1:5529 HOHMAN AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-1936
Practice Address - Country:US
Practice Address - Phone:219-934-9837
Practice Address - Fax:219-934-9816
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01047768A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200158950Medicaid
IL0090000854OtherBCBS GROUP NUMBER
IN200158950Medicaid
IL0090000854OtherBCBS GROUP NUMBER
IN140220TTMedicare PIN