Basic Information
Provider Information
NPI: 1003805805
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: KHWAJA
FirstName: ASIM
MiddleName: A.
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1125 E SOUTHERN AVE
Address2: SUITE 300
City: MESA
State: AZ
PostalCode: 852045045
CountryCode: US
TelephoneNumber: 4805458119
FaxNumber: 4809268332
Practice Location
Address1: 1125 E SOUTHERN AVE
Address2: SUITE 300
City: MESA
State: AZ
PostalCode: 852045045
CountryCode: US
TelephoneNumber: 4805458119
FaxNumber: 4809268332
Other Information
ProviderEnumerationDate: 10/14/2005
LastUpdateDate: 02/15/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2085R0202X28883AZY Allopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology

ID Information
IDTypeStateIssuerDescription
Z12376701AZMEDICARE ID FOR EVAC, LLCOTHER
54471905AZ MEDICAID


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