Healthcare Provider Details

I. General information

NPI: 1396884151
Provider Name (Legal Business Name): KULSOOM A KHAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KULSOOM ALVI KHAN M.D.

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 SCHOOL STREET
HARTFORD VT
05047-0709
US

IV. Provider business mailing address

390 RIVER ST
SPRINGFIELD VT
05156-2226
US

V. Phone/Fax

Practice location:
  • Phone: 802-295-3031
  • Fax: 802-295-0820
Mailing address:
  • Phone: 802-886-4500
  • Fax: 802-886-4520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC52915
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number042.0013685
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: