Basic Information
| Provider Information | |||||||||
| NPI: | 1457349474 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | ABDUL | ||||||||
| MiddleName: | LATEEF | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 323 YOLANDA LN | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711054337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3186173491 | ||||||||
| FaxNumber: | 3188614539 | ||||||||
| Practice Location | |||||||||
| Address1: | 1306 W COLLIN RAYE DR | ||||||||
| Address2: | |||||||||
| City: | DE QUEEN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 718322502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8706427572 | ||||||||
| FaxNumber: | 8705844100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 207Q00000X | LA200396 | LA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1053554 | 05 | LA | MEDICAID | E 4423 | 01 | AR | STATE LICENSE | OTHER | 2253429404 | 01 | LA | CDS | OTHER | BK 9331062 | 01 | LA | DEA | OTHER | LA 200396 | 01 | LA | STATE LICENSE | OTHER | 5N252 | 01 | AR | BCBS | OTHER | 157937001 | 05 | AR | MEDICAID | BK 9213163 | 01 | AR | DEA | OTHER |