Provider Demographics
NPI:1306137666
Name:KHAN, IMTIAZ R
Entity type:Individual
Prefix:
First Name:IMTIAZ
Middle Name:R
Last Name:KHAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2223 QUAIL RUN STE E
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-9063
Mailing Address - Country:US
Mailing Address - Phone:225-877-2872
Mailing Address - Fax:
Practice Address - Street 1:2223 QUAIL RUN STE E
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-9063
Practice Address - Country:US
Practice Address - Phone:225-877-2872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-21
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301505573208600000X, 208G00000X, 208G00000X
LA313117208600000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA56868Medicaid