Provider Demographics
NPI:1396884151
Name:KHAN, KULSOOM A (MD)
Entity type:Individual
Prefix:DR
First Name:KULSOOM
Middle Name:A
Last Name:KHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KULSOOM
Other - Middle Name:ALVI
Other - Last Name:KHAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:390 RIVER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:VT
Mailing Address - Zip Code:05156-2226
Mailing Address - Country:US
Mailing Address - Phone:802-886-4500
Mailing Address - Fax:802-886-4520
Practice Address - Street 1:49 SCHOOL STREET
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:VT
Practice Address - Zip Code:05047-0709
Practice Address - Country:US
Practice Address - Phone:802-295-3031
Practice Address - Fax:802-295-0820
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC529152084P0800X
VT042.00136852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1029599Medicaid
NHPENDINGMedicaid