Healthcare Provider Details

I. General information

NPI: 1184603755
Provider Name (Legal Business Name): FAWAD KHAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

600 WALNUT RIDGE DR
HARTLAND WI
53029-9385
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 262-369-7040
  • Fax:
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number38768
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: