Basic Information
| Provider Information | |||||||||
| NPI: | 1891834685 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | FAZAL | ||||||||
| MiddleName: | AB | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6416 OLD WINTER GARDEN RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328351348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4074477121 | ||||||||
| FaxNumber: | 4077700661 | ||||||||
| Practice Location | |||||||||
| Address1: | 5568 WESLAYAN ST | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770051942 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7136667050 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2007 | ||||||||
| LastUpdateDate: | 07/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036-117596 | IL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | N2592 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8BZ702 | 01 | TX | BCBS | OTHER | 201606501 | 05 | TX | MEDICAID |