Healthcare Provider Details

I. General information

NPI: 1265775225
Provider Name (Legal Business Name): AMIRAH NABIYAH KHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2013
Last Update Date: 05/17/2021
Certification Date: 05/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 QUINCY ST
BROCKTON MA
02302-2967
US

IV. Provider business mailing address

189 QUINCY ST
BROCKTON MA
02302-2967
US

V. Phone/Fax

Practice location:
  • Phone: 508-588-6700
  • Fax: 508-584-3010
Mailing address:
  • Phone: 508-588-6700
  • Fax: 508-584-3010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number266511
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: