Provider Demographics
NPI:1932193687
Name:KHAN, IQTIDAR A (M D)
Entity Type:Individual
Prefix:
First Name:IQTIDAR
Middle Name:A
Last Name:KHAN
Suffix:
Gender:M
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 BILL CLINTON DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:HOPE
Mailing Address - State:AR
Mailing Address - Zip Code:71801-8661
Mailing Address - Country:US
Mailing Address - Phone:870-777-2970
Mailing Address - Fax:870-722-6619
Practice Address - Street 1:302 BILL CLINTON DR
Practice Address - Street 2:SUITE 103
Practice Address - City:HOPE
Practice Address - State:AR
Practice Address - Zip Code:71801-8661
Practice Address - Country:US
Practice Address - Phone:870-777-2970
Practice Address - Fax:870-722-6619
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARE2934207R00000X
IN01072120A208M00000X
TXL9762207R00000X
PAMD445904207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201202110Medicaid
AR143742001Medicaid
AR90745000040OtherQUAL CHOICE
AR5L877OtherAR BCBS
IN000001015937OtherANTHEM PROVIDER NUMBER UNDER TIN 35-2030653
AR5L877OtherAR BCBS
IN815500153Medicare PIN
AR143742001Medicaid
TX264904YMSKMedicare PIN