Provider Demographics
NPI:1902803935
Name:KHAN, JIBRAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JIBRAN
Middle Name:
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 SHADY ROSE LN
Mailing Address - Street 2:
Mailing Address - City:MANVILLE
Mailing Address - State:RI
Mailing Address - Zip Code:02838-1044
Mailing Address - Country:US
Mailing Address - Phone:401-765-1200
Mailing Address - Fax:410-765-1212
Practice Address - Street 1:20 CUMBERLAND HILL RD
Practice Address - Street 2:SUITE 208
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895-4854
Practice Address - Country:US
Practice Address - Phone:401-765-1200
Practice Address - Fax:401-765-1212
Is Sole Proprietor?:No
Enumeration Date:2005-07-06
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI9516207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9020479Medicaid
RI9020479Medicaid