Basic Information
| Provider Information | |||||||||
| NPI: | 1609887942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHURRUM | ||||||||
| FirstName: | FATIMA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SALIM | ||||||||
| OtherFirstName: | FATIMA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2434 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468055406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604232675 | ||||||||
| FaxNumber: | 2604236621 | ||||||||
| Practice Location | |||||||||
| Address1: | 2434 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468055406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604232675 | ||||||||
| FaxNumber: | 2604236621 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| 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 | 11012596 | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.