Healthcare Provider Details

I. General information

NPI: 1639554181
Provider Name (Legal Business Name): SHAHBAZ ALI KHAN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2015
Last Update Date: 10/30/2021
Certification Date: 10/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 SEAVIEW AVE
STATEN ISLAND NY
10305-3436
US

IV. Provider business mailing address

475 SEAVIEW AVE
STATEN ISLAND NY
10305-3436
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-4037
  • Fax:
Mailing address:
  • Phone: 718-226-4124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZH0000X
TaxonomyHematology (Pathology) Physician
License Number298212
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number31464
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number298212
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: