Healthcare Provider Details

I. General information

NPI: 1669416160
Provider Name (Legal Business Name): EJAZ M KHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 01/09/2024
Certification Date: 01/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 WATKINS PARK DR
UPPER MARLBORO MD
20774-1628
US

IV. Provider business mailing address

20 WATKINS PARK DR
UPPER MARLBORO MD
20774-1628
US

V. Phone/Fax

Practice location:
  • Phone: 301-350-8500
  • Fax: 540-350-8503
Mailing address:
  • Phone: 301-350-8500
  • Fax: 540-350-8503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0092421
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number0101239751
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number25MA09948900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: