Provider Demographics
NPI:1528677085
Name:KHAN, MARIAM
Entity type:Individual
Prefix:
First Name:MARIAM
Middle Name:
Last Name:KHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S WOODLAND ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-3546
Mailing Address - Country:US
Mailing Address - Phone:407-409-2222
Mailing Address - Fax:407-905-8998
Practice Address - Street 1:19108 E COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32820-3701
Practice Address - Country:US
Practice Address - Phone:407-905-8827
Practice Address - Fax:407-660-1667
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-30
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07432300208000000X
FLME154297208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics