Basic Information
| Provider Information | |||||||||
| NPI: | 1811551716 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | MARINA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 DORCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | DORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172964000 | ||||||||
| FaxNumber: | 6176388984 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 DORCHESTER AVE | ||||||||
| Address2: | |||||||||
| City: | DORCHESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021245666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6172964000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2019 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 281156 | MA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.