Healthcare Provider Details

I. General information

NPI: 1508153867
Provider Name (Legal Business Name): FARAH KHAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 03/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 SAVANNAH DR
DEFOREST WI
53532-2909
US

IV. Provider business mailing address

202 S PARK ST
MADISON WI
53715-1507
US

V. Phone/Fax

Practice location:
  • Phone: 608-417-3300
  • Fax: 608-417-3333
Mailing address:
  • Phone: 608-417-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2014-00863
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberP4068
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number65053
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: