Healthcare Provider Details

I. General information

NPI: 1780608638
Provider Name (Legal Business Name): MIR IFTEKHAR ALI-KHAN M.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 02/02/2021
Certification Date: 01/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 E DEL MAR BLVD
PASADENA CA
91107-4375
US

IV. Provider business mailing address

2058 MILLS AVE PO BOX 350
CLAREMONT CA
91711
US

V. Phone/Fax

Practice location:
  • Phone: 626-795-9901
  • Fax: 818-845-0528
Mailing address:
  • Phone: 818-845-3510
  • Fax: 818-845-0528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA48827
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: