Provider Demographics
NPI:1528089158
Name:KHAN, ALI A (MD)
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:A
Last Name:KHAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:527 MEDICAL PARK DRIVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330
Mailing Address - Country:US
Mailing Address - Phone:304-933-3800
Mailing Address - Fax:304-933-3815
Practice Address - Street 1:2 HARTMAN PLZ
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-2230
Practice Address - Country:US
Practice Address - Phone:304-471-3400
Practice Address - Fax:304-471-3402
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2013-12-18
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
WV17611207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0076674000Medicaid
WV0076674000Medicaid
WVF52085Medicare UPIN