Basic Information
Provider Information | |||||||||
NPI: | 1639457260 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KHAN | ||||||||
FirstName: | HABIB | ||||||||
MiddleName: | AHMAD | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 S WELLS RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | VENTURA | ||||||||
State: | CA | ||||||||
PostalCode: | 930041377 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056591740 | ||||||||
FaxNumber: | 8056593217 | ||||||||
Practice Location | |||||||||
Address1: | 200 S WELLS RD | ||||||||
Address2: | SUITE 200 | ||||||||
City: | VENTURA | ||||||||
State: | CA | ||||||||
PostalCode: | 930041377 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056591740 | ||||||||
FaxNumber: | 8056593217 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2011 | ||||||||
LastUpdateDate: | 06/30/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/30/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A129432 | CA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 390200000X | 4301099080 | MI | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207QH0002X | H89660 | MD | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Hospice and Palliative Medicine |
No ID Information.