Healthcare Provider Details

I. General information

NPI: 1700846169
Provider Name (Legal Business Name): TARIQ A. KHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 06/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 OAK PARK BLVD 3RD FL
LAKE CHARLES LA
70601-8991
US

IV. Provider business mailing address

PO BOX 122108 DEPT 2108
DALLAS TX
75312-2108
US

V. Phone/Fax

Practice location:
  • Phone: 337-475-8100
  • Fax: 337-475-8510
Mailing address:
  • Phone: 337-475-8100
  • Fax: 337-475-8510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number12962R
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: