Healthcare Provider Details

I. General information

NPI: 1093758518
Provider Name (Legal Business Name): NIKHAT S KHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 ROUTE 112 SUITE 101
CORAM NY
11727-4131
US

IV. Provider business mailing address

3650 ROUTE 112 SUITE 101
CORAM NY
11727-4131
US

V. Phone/Fax

Practice location:
  • Phone: 631-716-0851
  • Fax: 631-716-0852
Mailing address:
  • Phone: 631-716-0851
  • Fax: 631-716-0852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number166404
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: