Basic Information
| Provider Information | |||||||||
| NPI: | 1972690253 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | ZIA | ||||||||
| MiddleName: | AHMED | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 737 OAKMERE PL | ||||||||
| Address2: | |||||||||
| City: | NORTH MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494452852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317444129 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 376 E APPLE AVE | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494423466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317243699 | ||||||||
| FaxNumber: | 2317243659 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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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 | 4301052980 | MI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 4763787 | 05 | MI | MEDICAID | ZK052980 | 01 | MI | BCBS PIN | OTHER |