Healthcare Provider Details

I. General information

NPI: 1205818911
Provider Name (Legal Business Name): DASTAGIR ALAM KHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27 DYKE RD
LATHAM NY
12110-1237
US

IV. Provider business mailing address

27 DYKE RD
LATHAM NY
12110-1237
US

V. Phone/Fax

Practice location:
  • Phone: 904-955-7190
  • Fax:
Mailing address:
  • Phone: 904-955-7190
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number281049
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number281049
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: