Provider Demographics
NPI:1972692358
Name:KHAN, SHAUKAT A (MD)
Entity type:Individual
Prefix:DR
First Name:SHAUKAT
Middle Name:A
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 1:4100 EMBASSY DR SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-2416
Mailing Address - Country:US
Mailing Address - Phone:616-459-6146
Mailing Address - Fax:616-459-9277
Practice Address - Street 1:1320 N MICHIGAN AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4751
Practice Address - Country:US
Practice Address - Phone:989-583-7460
Practice Address - Fax:989-583-7432
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI382109126207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISK032760OtherBCBS
P53670001Medicare PIN
MIB44153Medicare UPIN