Healthcare Provider Details

I. General information

NPI: 1669430567
Provider Name (Legal Business Name): FAZAL KHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 04/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10350 HALIGUS RD
HUNTLEY IL
60142-9558
US

IV. Provider business mailing address

13707 W JACKSON ST
WOODSTOCK IL
60098-3188
US

V. Phone/Fax

Practice location:
  • Phone: 815-338-6600
  • Fax: 847-802-7203
Mailing address:
  • Phone: 815-337-1871
  • Fax: 815-338-6297

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036104590
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: