Provider Demographics
NPI:1124347984
Name:KHAN, SHAMSUL ALAM (MD)
Entity type:Individual
Prefix:
First Name:SHAMSUL
Middle Name:ALAM
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:ROCKINGHAM
Mailing Address - State:NC
Mailing Address - Zip Code:28380-0100
Mailing Address - Country:US
Mailing Address - Phone:910-895-4140
Mailing Address - Fax:910-895-4091
Practice Address - Street 1:1219 ROCKINGHAM RD
Practice Address - Street 2:SUITE#3
Practice Address - City:ROCKINGHAM
Practice Address - State:NC
Practice Address - Zip Code:28379-4983
Practice Address - Country:US
Practice Address - Phone:910-895-4140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-19
Last Update Date:2010-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9601645208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891030AMedicaid