Healthcare Provider Details

I. General information

NPI: 1659604304
Provider Name (Legal Business Name): NASEERUDDIN GULAM KHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2009
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5742 N CHRISTIANA AVE APT 1S
CHICAGO IL
60659-4595
US

IV. Provider business mailing address

5742 N CHRISTIANA AVE APT 1S
CHICAGO IL
60659-4595
US

V. Phone/Fax

Practice location:
  • Phone: 773-989-3344
  • Fax: 773-989-8458
Mailing address:
  • Phone: 773-989-3344
  • Fax: 773-989-8458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036126888
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: