Provider Demographics
NPI:1265691364
Name:KHATTAK, HIMAD ULLAH KHAN (MD)
Entity type:Individual
Prefix:
First Name:HIMAD ULLAH
Middle Name:KHAN
Last Name:KHATTAK
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 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3191
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:103 MCKNIGHT DR STE A
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45044-4891
Practice Address - Country:US
Practice Address - Phone:513-217-6400
Practice Address - Fax:513-217-6037
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008014651207R00000X, 208M00000X
OH35123560207R00000X
OH35.123560207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0119424Medicaid