Healthcare Provider Details

I. General information

NPI: 1568996338
Provider Name (Legal Business Name): TALHA M KHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2017
Last Update Date: 04/16/2025
Certification Date: 04/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19712 MACARTHUR BLVD STE 100
IRVINE CA
92612-2407
US

IV. Provider business mailing address

19712 MACARTHUR BLVD STE 100
IRVINE CA
92612-2407
US

V. Phone/Fax

Practice location:
  • Phone: 949-486-8530
  • Fax: 949-486-8531
Mailing address:
  • Phone: 949-486-8530
  • Fax: 949-486-8531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberMD472566
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA195411
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: