Healthcare Provider Details

I. General information

NPI: 1730282666
Provider Name (Legal Business Name): SHAHNAWAZ AHMED KHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2533 AUGUSTINE HERMAN HWY SUITE A
CHESAPEAKE CITY MD
21915-1414
US

IV. Provider business mailing address

2533 AUGUSTINE HERMAN HWY SUITE A
CHESAPEAKE CITY MD
21915
US

V. Phone/Fax

Practice location:
  • Phone: 410-885-5018
  • Fax: 410-885-5026
Mailing address:
  • Phone: 410-885-5018
  • Fax: 410-885-5026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number22462
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD0062190
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC1-0009568
License Number StateDE
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number22462
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: