Healthcare Provider Details

I. General information

NPI: 1396804662
Provider Name (Legal Business Name): TARIQ ASADULLAH KHAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 05/01/2024
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4221 S WESTERN AVE STE 5020
OKLAHOMA CITY OK
73109-3445
US

IV. Provider business mailing address

4221 S WESTERN AVE STE 5020
OKLAHOMA CITY OK
73109-3445
US

V. Phone/Fax

Practice location:
  • Phone: 405-768-5904
  • Fax:
Mailing address:
  • Phone: 405-768-5904
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0000X
TaxonomyAdolescent Medicine (Internal Medicine) Physician
License Number2004009683
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number33459
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: