Provider Demographics
NPI:1770569022
Name:KHAN, SHABANA (MD)
Entity type:Individual
Prefix:DR
First Name:SHABANA
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 1:861 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2308
Mailing Address - Country:US
Mailing Address - Phone:313-274-1800
Mailing Address - Fax:313-274-8717
Practice Address - Street 1:861 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2308
Practice Address - Country:US
Practice Address - Phone:313-274-1800
Practice Address - Fax:313-274-8717
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046990207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1770569022Medicaid
MI503292OtherCARE-PREFERRED CHOICES
MI700H222490OtherBLUE SHIELD
MI503292OtherCARE-PREFERRED CHOICES
MID83196Medicare UPIN