=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497174494
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FAHAD ULLAH KHAN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2014
-----------------------------------------------------
Last Update Date | 10/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3500 MCCLURE BRIDGE RD
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30096-3131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-476-3636
-----------------------------------------------------
Fax | 770-476-5845
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3500 MCCLURE BRIDGE RD
-----------------------------------------------------
City | DULUTH
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30096-3131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-476-3636
-----------------------------------------------------
Fax | 770-476-5845
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | R3528
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 88952
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------