Provider Demographics
NPI:1780857854
Name:KHAN, PERVEZ ALI (MD)
Entity type:Individual
Prefix:
First Name:PERVEZ
Middle Name:ALI
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 SOUTHPARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:LACKAWANNA
Mailing Address - State:NY
Mailing Address - Zip Code:14218-1504
Mailing Address - Country:US
Mailing Address - Phone:716-822-2028
Mailing Address - Fax:716-822-2029
Practice Address - Street 1:2600 SOUTHPARK AVENUE
Practice Address - Street 2:
Practice Address - City:LACKAWANNA
Practice Address - State:NY
Practice Address - Zip Code:14218-1504
Practice Address - Country:US
Practice Address - Phone:716-822-2028
Practice Address - Fax:716-822-2029
Is Sole Proprietor?:No
Enumeration Date:2008-04-09
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY125843208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2197231OtherCOVENTRY
NY4538333OtherAETNA
NYRB8099OtherMEDICARE RAILROAD
NY02961200Medicaid
NYP00608133Medicare PIN