Healthcare Provider Details

I. General information

NPI: 1700016854
Provider Name (Legal Business Name): WAQAS AHMAD KHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2009
Last Update Date: 12/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 N WATERMAN AVE
SAN BERNARDINO CA
92404-4836
US

IV. Provider business mailing address

5410 MARYLAND WAY SUITE 300
BRENTWOOD TN
37027-5064
US

V. Phone/Fax

Practice location:
  • Phone: 909-881-4520
  • Fax: 909-881-4526
Mailing address:
  • Phone: 615-377-5600
  • Fax: 949-567-9827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA 108929
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA 108929
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036133312
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: