Basic Information
| Provider Information | |||||||||
| NPI: | 1629075387 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHOKHAR | ||||||||
| FirstName: | IMTIAZ | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75 NORTH COUNTRY ROAD | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314731320 | ||||||||
| FaxNumber: | 6316867972 | ||||||||
| Practice Location | |||||||||
| Address1: | 75 NORTH COUNTRY ROAD | ||||||||
| Address2: | |||||||||
| City: | PORT JEFFERSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314731320 | ||||||||
| FaxNumber: | 6316867972 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 02/06/2018 | ||||||||
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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 | 197453 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01720465 | 05 | NY | MEDICAID |