Provider Demographics
NPI:1881691368
Name:KHAN, ATIYA S (MD)
Entity type:Individual
Prefix:
First Name:ATIYA
Middle Name:S
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 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11115 PARKVIEW PLAZA DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1701
Practice Address - Country:US
Practice Address - Phone:260-266-5400
Practice Address - Fax:260-266-5405
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059831A2084N0400X, 2084S0012X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084S0012XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologySleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200507010Medicaid
OH2168078Medicaid
MI4851469Medicaid
INP00200805OtherRR MEDICARE
IN668120RMedicare PIN
OH2168078Medicaid
MI4851469Medicaid
INP00200805Medicare PIN
IN200507010Medicaid
IN252800AMedicare PIN