Healthcare Provider Details

I. General information

NPI: 1497018410
Provider Name (Legal Business Name): AHMED FASIHUDDIN KHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 03/01/2025
Certification Date: 03/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 1ST ST STE A
SAN FRANCISCO CA
94105-2661
US

IV. Provider business mailing address

PO BOX 4039
ORANGE CA
92863-4039
US

V. Phone/Fax

Practice location:
  • Phone: 888-803-3370
  • Fax:
Mailing address:
  • Phone: 714-571-5000
  • Fax: 714-571-5055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA161223
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: