Basic Information
| Provider Information | |||||||||
| NPI: | 1629162359 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | WAJID | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 185 PENNY AVE | ||||||||
| Address2: | |||||||||
| City: | EAST DUNDEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601181454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8478367015 | ||||||||
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| Practice Location | |||||||||
| Address1: | 200 N HAMMES AVE | ||||||||
| Address2: | SUITE 3 | ||||||||
| City: | JOLIET | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604356677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157448253 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 10/15/2012 | ||||||||
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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 | 2084P0800X | 036115038 | IL | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 036115038 | 05 | IL | MEDICAID | 0991516762 | 01 | IL | BCBS | OTHER |