Healthcare Provider Details

I. General information

NPI: 1013940147
Provider Name (Legal Business Name): TAWFIQ IFTEKHAR KHANSUR M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 E WOODROW WILSON AVE
JACKSON MS
39216-5116
US

IV. Provider business mailing address

1500 E WOODROW WILSON AVE
JACKSON MS
39216-5116
US

V. Phone/Fax

Practice location:
  • Phone: 601-364-4471
  • Fax: 601-364-1588
Mailing address:
  • Phone: 601-364-4471
  • Fax: 601-364-1588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number08894
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: