Provider Demographics
NPI:1538163969
Name:KHAN, ABDUS SALAM (MD)
Entity type:Individual
Prefix:DR
First Name:ABDUS
Middle Name:SALAM
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:PO BOX 30069
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33630-3069
Mailing Address - Country:US
Mailing Address - Phone:386-676-0255
Mailing Address - Fax:386-676-2555
Practice Address - Street 1:301 MEMORIAL MEDICAL PARKWAY
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33174-1804
Practice Address - Country:US
Practice Address - Phone:386-231-3346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME-0071027207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL295858OtherAVMED UC
FL32566OtherBCBS INDIVIDUAL
FL10560801OtherCITRUS GROUP UC
FL2589619OtherGHI
FL269227900Medicaid
FLP00141526OtherRR INDIVIDUAL
FL285718OtherWELLCARE UC
FL3535562OtherAETNA UC
FL08802OtherUNIVERAL UC
FL200656648OtherTAX ID
FL289370OtherAMERIGROUP UC
FLDB9962OtherRR GROUP
FLME0071027OtherMEDICAL LICENSE
FL000029271OtherHUMANA UC
FL251002200Medicaid
FL10560601OtherCITRUS INDIVIDUAL
FLB903UOtherBCBS GROUP UC
FLP00141526OtherRR INDIVIDUAL
FL10560601OtherCITRUS INDIVIDUAL
FLDB9962OtherRR GROUP