Healthcare Provider Details

I. General information

NPI: 1912861956
Provider Name (Legal Business Name): SHAHID KHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 BIRCH WAY
VALLEY STREAM NY
11581-2628
US

IV. Provider business mailing address

18 BIRCH WAY
VALLEY STREAM NY
11581-2628
US

V. Phone/Fax

Practice location:
  • Phone: 347-430-1388
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberP139758
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: