1104972991 NPI number — CRISTINA ELDIDY KHAN DPT

Table of content: CRISTINA ELDIDY KHAN DPT (NPI 1104972991)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104972991 NPI number — CRISTINA ELDIDY KHAN DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KHAN
Provider First Name:
CRISTINA
Provider Middle Name:
ELDIDY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPT
Provider Gender Code:
F

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:
1104972991
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 3RD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM BEACH GARDENS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33418-3547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-691-0967
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8895 N MILITARY TRL
Provider Second Line Business Practice Location Address:
BLDG E, SUITE 101
Provider Business Practice Location Address City Name:
WEST PALM BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33410-6220
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-624-1457
Provider Business Practice Location Address Fax Number:
561-775-3290
Provider Enumeration Date:
01/26/2007

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: 225100000X , with the licence number:  PT 22767 , 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: 891536900 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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