Healthcare Provider Details

I. General information

NPI: 1205754967
Provider Name (Legal Business Name): AZIZULLAH KHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 MICHIGAN ST NE
GRAND RAPIDS MI
49503-2550
US

IV. Provider business mailing address

111 SWEET ST NE
GRAND RAPIDS MI
49505-4601
US

V. Phone/Fax

Practice location:
  • Phone: 616-774-2822
  • Fax: 616-391-8665
Mailing address:
  • Phone: 616-774-2822
  • Fax: 616-391-8665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number4351056747
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: