MEDICARE: SIDDIQA K 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	207Q00000X	Family Medicine Physician	90990	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	3164176	OTHER	FL	CIGNA
2	392117	OTHER	FL	HEALTHEASE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	298827	OTHER	FL	AV MED
5	2064269	OTHER	FL	FIRST COAST ADVANTAGE

General Provider Information

NPI Number	:	1740289180
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SIDDIQA K KHAN MD

Provider Business Mailing Address
First Line	:	1833 BOULEVARD
Second Line	:	JACLSONVILLE VA OUTPATIENT CLINIC
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-4382
Country	:	US
Telephone Number	:	904-232-2751
Fax Number	:	904-301-2502

Provider Business Practice Location Address
First Line	:	1833 BOULEVARD
Second Line	:	VA OUTPATIENT CLINIC
City	:	JACKSONVILLE
State	:	FL
Zip	:	32206-4382
Country	:	US
Telephone Number	:	904-232-2751
Fax Number	:	904-301-2502

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

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	04/07/2011

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Directions to “ SIDDIQA K KHAN MD” Practice Location

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