Basic Information
| Provider Information | |||||||||
| NPI: | 1154367290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | SHAZIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SALAH | ||||||||
| OtherFirstName: | SHAZIA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8197 LAWRENCE RD | ||||||||
| Address2: | |||||||||
| City: | WEST CHESTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5137795215 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 930 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45044 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5134258305 | ||||||||
| FaxNumber: | 5134251810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35085441 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2602615 | 05 | OH | MEDICAID | A298815 | 01 | AMERIGROUP | OTHER |