Provider Demographics
NPI:1174521603
Name:KHAN, WALI U (MD)
Entity type:Individual
Prefix:
First Name:WALI
Middle Name:U
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:PO BOX 48589
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33646-0122
Mailing Address - Country:US
Mailing Address - Phone:813-715-4446
Mailing Address - Fax:813-780-7786
Practice Address - Street 1:37914 DAUGHTERY RD
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33541-1316
Practice Address - Country:US
Practice Address - Phone:813-715-4446
Practice Address - Fax:813-780-7786
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2017-04-06
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-04-12
Provider Licenses
StateLicense IDTaxonomies
FLME41877207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL204252500Medicaid
FL060069167OtherRAILROAD MEDICARE
51195WMedicare PIN
FL060069167OtherRAILROAD MEDICARE