MEDICARE: WASEEMULLAH KHAN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RX0202X	Medical Oncology Physician	ME76931	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	PTAN 01693W	OTHER	FL	LINKED TO GROUP PTAN IE881A EFFECTIVE 07/01/15
3	830008471	OTHER	FL	RR MCR
4	279199	OTHER	FL	AVMED
5	01693	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1073557864
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WASEEMULLAH KHAN MD

Provider Business Mailing Address
First Line	:	289 SW STONEGATE TER STE 103
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32024-3457
Country	:	US
Telephone Number	:	386-755-1655
Fax Number	:	386-755-2330

Provider Business Practice Location Address
First Line	:	289 SW STONEGATE TER
Second Line	:	SUITE103
City	:	LAKE CITY
State	:	FL
Zip	:	32024-3457
Country	:	US
Telephone Number	:	386-755-1655
Fax Number	:	386-628-9231

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2006
Last Update Date	:	12/30/2024

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