Provider Demographics
NPI:1366430076
Name:KHAN, SHABAZ ALI (MD)
Entity type:Individual
Prefix:
First Name:SHABAZ
Middle Name:ALI
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14131 MIDWAY RD
Mailing Address - Street 2:SUITE 620
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3623
Mailing Address - Country:US
Mailing Address - Phone:972-249-0200
Mailing Address - Fax:972-249-0206
Practice Address - Street 1:14131 MIDWAY RD
Practice Address - Street 2:SUITE 620
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-3623
Practice Address - Country:US
Practice Address - Phone:972-249-0200
Practice Address - Fax:972-249-0206
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2014-03-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN028345207R00000X
TXM2671207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX182315501Medicaid
TX8P5792OtherBCBS
GA000728714AMedicaid
G35117Medicare UPIN
GA000728714AMedicaid
TX8G7270Medicare PIN