Provider Demographics
NPI:1801888037
Name:KHATTAK, SAMINA NIAZ (MD)
Entity type:Individual
Prefix:
First Name:SAMINA
Middle Name:NIAZ
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 1:8400 LOUISIANA ST
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-6385
Mailing Address - Country:US
Mailing Address - Phone:219-757-1928
Mailing Address - Fax:219-757-1950
Practice Address - Street 1:3903 INDIANAPOLIS BLVD
Practice Address - Street 2:
Practice Address - City:EAST CHICAGO
Practice Address - State:IN
Practice Address - Zip Code:46312-2555
Practice Address - Country:US
Practice Address - Phone:219-398-7050
Practice Address - Fax:219-392-6998
Is Sole Proprietor?:No
Enumeration Date:2005-08-15
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057204A2084P0800X
IL036-0962022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000272808OtherANTHEM BCBS
IN200424330Medicaid
IN387080WMedicare ID - Type Unspecified