MEDICARE: DR. KASSIM A. KHAN M.D.

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	207W00000X	Ophthalmology Physician	H7171	TX

General Provider Information

NPI Number	:	1235126731
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KASSIM A. KHAN M.D.

Provider Business Mailing Address
First Line	:	1001 12TH AVE
Second Line	:	SUITE 132
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3926
Country	:	US
Telephone Number	:	817-870-2010
Fax Number	:	817-870-2050

Provider Business Practice Location Address
First Line	:	1001 12TH AVE
Second Line	:	SUITE 132
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3926
Country	:	US
Telephone Number	:	817-870-2010
Fax Number	:	817-870-2050

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

Provider Enumeration Date	:	09/30/2005
Last Update Date	:	10/20/2009

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