=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114067667
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MANSOOR A. KHAN MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2007
-----------------------------------------------------
Last Update Date | 04/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 224 HAMBURG TPKE WAYNE GENERAL HOSPITAL
-----------------------------------------------------
City | WAYNE
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07470-2111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-754-2150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3 CENTURY DR
-----------------------------------------------------
City | PARSIPPANY
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07054-4610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-345-0064
-----------------------------------------------------
Fax | 973-740-1350
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | R5881
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | 25MA08206300
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------