Healthcare Provider Details

I. General information

NPI: 1366431967
Provider Name (Legal Business Name): ANWAR M KHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 11/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 SAYBROOK RD
MIDDLETOWN CT
06457-4783
US

IV. Provider business mailing address

760 SAYBROOK RD
MIDDLETOWN CT
06457-4785
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-2100
  • Fax: 860-358-2110
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number041428
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: