Provider Demographics
NPI:1881804938
Name:KHWAJA, TAHIR NISAR (MD)
Entity type:Individual
Prefix:DR
First Name:TAHIR
Middle Name:NISAR
Last Name:KHWAJA
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 1:10506 SANCREST RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23238-4131
Mailing Address - Country:US
Mailing Address - Phone:917-287-8207
Mailing Address - Fax:
Practice Address - Street 1:1460 LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:NORTH BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08902-1873
Practice Address - Country:US
Practice Address - Phone:917-287-8207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD606541472084P0800X
TXS36912084P0804X
VA01012465312084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAGC1100Medicare PIN
VAVV1694AMedicare PIN