Provider Demographics
NPI:1073557864
Name:KHAN, WASEEMULLAH (MD)
Entity type:Individual
Prefix:
First Name:WASEEMULLAH
Middle Name:
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:WASEEMULLAH
Other - Middle Name:
Other - Last Name:KHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:289 SW STONEGATE TER STE 103
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32024-3457
Mailing Address - Country:US
Mailing Address - Phone:386-755-1655
Mailing Address - Fax:386-755-2330
Practice Address - Street 1:289 SW STONEGATE TER
Practice Address - Street 2:SUITE103
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32024-3457
Practice Address - Country:US
Practice Address - Phone:386-755-1655
Practice Address - Fax:386-628-9231
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME76931207RX0202X, 207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL262534200Medicaid
FLPTAN 01693WOtherLINKED TO GROUP PTAN IE881A EFFECTIVE 07/01/15
FL830008471OtherRR MCR
FL279199OtherAVMED
FL01693OtherBCBS
FL01693XMedicare PIN