Healthcare Provider Details

I. General information

NPI: 1386619583
Provider Name (Legal Business Name): HIDAYAT KHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 TOLL HOUSE AVE
FREDERICK MD
21701-4564
US

IV. Provider business mailing address

4221 BUCKSKIN WOOD DR
ELLICOTT CITY MD
21042-1217
US

V. Phone/Fax

Practice location:
  • Phone: 301-694-4935
  • Fax: 301-694-0389
Mailing address:
  • Phone: 301-694-4935
  • Fax: 301-694-0389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberD0023240
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: