Healthcare Provider Details

I. General information

NPI: 1750808697
Provider Name (Legal Business Name): ASIF ALI KHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

396 BROADWAY
KINGSTON NY
12401-4626
US

IV. Provider business mailing address

47 TENNYSON WAY
PITTSFORD NY
14534-9528
US

V. Phone/Fax

Practice location:
  • Phone: 845-331-3131
  • Fax: 845-331-2530
Mailing address:
  • Phone: 607-968-1983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number99620
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number290583
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: