Healthcare Provider Details

I. General information

NPI: 1528677085
Provider Name (Legal Business Name): MARIAM KHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2020
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19108 E COLONIAL DR
ORLANDO FL
32820-3701
US

IV. Provider business mailing address

110 S WOODLAND ST
WINTER GARDEN FL
34787-3546
US

V. Phone/Fax

Practice location:
  • Phone: 407-905-8827
  • Fax: 407-660-1667
Mailing address:
  • Phone: 407-409-2222
  • Fax: 407-905-8998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA07432300
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME154297
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: