Basic Information
Provider Information | |||||||||
NPI: | 1548554132 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KHAN | ||||||||
FirstName: | JAWARIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ALAM | ||||||||
OtherFirstName: | JAWARIA | ||||||||
OtherMiddleName: | KHAN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 413021 | ||||||||
Address2: | DEPARTMENT OF PEDIATRICS UNIVERSITY OF UTAH | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841413021 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8012133900 | ||||||||
FaxNumber: | 8015853655 | ||||||||
Practice Location | |||||||||
Address1: | 100 MARIO CAPECCHI DR | ||||||||
Address2: | PRIMARY CHILDREN'S MEDICAL CENTER INPATIENT SERVICES | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841131103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8016625700 | ||||||||
FaxNumber: | 8016625755 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/01/2011 | ||||||||
LastUpdateDate: | 11/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 208000000X | 84361541205 | UT | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.