Healthcare Provider Details

I. General information

NPI: 1073557864
Provider Name (Legal Business Name): WASEEMULLAH KHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: WASEEMULLAH KHAN MD

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 SW STONEGATE TER SUITE103
LAKE CITY FL
32024-3457
US

IV. Provider business mailing address

289 SW STONEGATE TER STE 103
LAKE CITY FL
32024-3457
US

V. Phone/Fax

Practice location:
  • Phone: 386-755-1655
  • Fax: 386-628-9231
Mailing address:
  • Phone: 386-755-1655
  • Fax: 386-755-2330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberME76931
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: