Provider Demographics
NPI:1902327240
Name:KHAN, PROTIVA SHOOPROVA (OD)
Entity Type:Individual
Prefix:
First Name:PROTIVA
Middle Name:SHOOPROVA
Last Name:KHAN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2912 WILLOWBROOK DR APT 3
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95348-1301
Mailing Address - Country:US
Mailing Address - Phone:213-820-6350
Mailing Address - Fax:
Practice Address - Street 1:5192 HOSPITAL ROAD
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338
Practice Address - Country:US
Practice Address - Phone:209-742-6144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV008592-1152W00000X
CA34680152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty