Provider Demographics
NPI:1174625404
Name:KHAN, MILLY PERVEEN (MD)
Entity type:Individual
Prefix:DR
First Name:MILLY
Middle Name:PERVEEN
Last Name:KHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MILLY
Other - Middle Name:
Other - Last Name:PERVEEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1776 E CENTURY BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90002-3050
Mailing Address - Country:US
Mailing Address - Phone:323-374-6848
Mailing Address - Fax:323-889-7821
Practice Address - Street 1:1776 E CENTURY BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-3050
Practice Address - Country:US
Practice Address - Phone:323-374-6848
Practice Address - Fax:323-889-7821
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC141332207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01463301Medicaid
PAF-77202Medicare UPIN
PA763106Medicare ID - Type Unspecified