1538163969 NPI number — DR. ABDUS SALAM KHAN MD

Table of content: DR. ABDUS SALAM KHAN MD (NPI 1538163969)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538163969 NPI number — DR. ABDUS SALAM KHAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHAN
Provider First Name:
ABDUS
Provider Middle Name:
SALAM
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538163969
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30069
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33630-3069
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-676-0255
Provider Business Mailing Address Fax Number:
386-676-2555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 MEMORIAL MEDICAL PARKWAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAYTONA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33174-1804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-231-3346
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  ME-0071027 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 295858 . This is a "AVMED UC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 32566 . This is a "BCBS INDIVIDUAL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 10560801 . This is a "CITRUS GROUP UC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 2589619 . This is a "GHI" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 269227900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00141526 . This is a "RR INDIVIDUAL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 285718 . This is a "WELLCARE UC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 3535562 . This is a "AETNA UC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 08802 . This is a "UNIVERAL UC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 200656648 . This is a "TAX ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 289370 . This is a "AMERIGROUP UC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: DB9962 . This is a "RR GROUP" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: ME0071027 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 000029271 . This is a "HUMANA UC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 251002200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10560601 . This is a "CITRUS INDIVIDUAL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: B903U . This is a "BCBS GROUP UC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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