Healthcare Provider Details

I. General information

NPI: 1417138157
Provider Name (Legal Business Name): SHUJAAT A KHAN M D P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2007
Last Update Date: 09/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 8TH AVE STE 404
FORT WORTH TX
76104
US

IV. Provider business mailing address

800 8TH AVE STE 404
FORT WORTH TX
76104
US

V. Phone/Fax

Practice location:
  • Phone: 817-335-6363
  • Fax: 817-870-1222
Mailing address:
  • Phone: 817-335-6363
  • Fax: 817-870-1222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberE5132
License Number StateTX

VIII. Authorized Official

Name: DR. SHUJAAT A KHAN
Title or Position: PRESIDENT
Credential: MD
Phone: 817-335-6363