Provider Demographics
NPI:1306936349
Name:KHAN, JAKAULLA (MD)
Entity type:Individual
Prefix:DR
First Name:JAKAULLA
Middle Name:
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 1:1739 E BEVERLY AVE
Mailing Address - Street 2:STE 208
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-3593
Mailing Address - Country:US
Mailing Address - Phone:201-512-9494
Mailing Address - Fax:
Practice Address - Street 1:1003 MAIN AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2333
Practice Address - Country:US
Practice Address - Phone:973-777-9595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37755207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6707301Medicaid
NJG10168Medicare UPIN
NJ787919Medicare ID - Type Unspecified