Basic Information
| Provider Information | |||||||||
| NPI: | 1265691364 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHATTAK | ||||||||
| FirstName: | HIMAD ULLAH | ||||||||
| MiddleName: | KHAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD BLDG B3 | ||||||||
| Address2: | |||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913191 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 MCKNIGHT DR STE A | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450444891 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5132176400 | ||||||||
| FaxNumber: | 5132176037 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2008 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2008014651 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 35123560 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 2008014651 | MO | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RC0000X | 35.123560 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 0119424 | 05 | OH | MEDICAID |