Basic Information
| Provider Information | |||||||||
| NPI: | 1700016854 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KHAN | ||||||||
| FirstName: | WAQAS | ||||||||
| MiddleName: | AHMAD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5410 MARYLAND WAY | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275064 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153775600 | ||||||||
| FaxNumber: | 9495679827 | ||||||||
| Practice Location | |||||||||
| Address1: | 2101 N WATERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924044836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098814520 | ||||||||
| FaxNumber: | 9098814526 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2009 | ||||||||
| LastUpdateDate: | 12/14/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A 108929 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | A 108929 | CA | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 036133312 | IL | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0A1089290 | 01 | CA | BLUE SHIELD | OTHER |