Healthcare Provider Details

I. General information

NPI: 1073588943
Provider Name (Legal Business Name): AZMATHULLAH KHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4700 GREENFIELD RD
DEARBORN MI
48126-4124
US

IV. Provider business mailing address

4700 GREENFIELD RD
DEARBORN MI
48126-4124
US

V. Phone/Fax

Practice location:
  • Phone: 313-945-6100
  • Fax: 313-945-5260
Mailing address:
  • Phone: 313-945-6100
  • Fax: 313-945-5260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberAK065422
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: