Healthcare Provider Details

I. General information

NPI: 1417887514
Provider Name (Legal Business Name): FARDIN KHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 CLARKSON AVE
BROOKLYN NY
11203-2097
US

IV. Provider business mailing address

4723 49TH ST
WOODSIDE NY
11377-6748
US

V. Phone/Fax

Practice location:
  • Phone: 646-320-7602
  • Fax:
Mailing address:
  • Phone: 929-330-9483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: